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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICESRE *Prar <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 �#E t L) <br /> (209) 468-3447 APR 8 1991 <br /> iNVIRQNMENTAL HEALTH <br /> l (Complete in Triplicate) PERMIT/ <br /> Application is her made to San Joaquin County for a permit to construct and/or install the vork herein �deecribed. This <br /> application Is made in c6411ance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulationa of San <br /> Joaquin County blic Heilth Services. <br /> Iullb <br /> Job Address L� City Lot Size/Acreage <br /> I�. Phone <br /> Owner's Na gy <br /> I <br /> Contract t I_,�r/ Address icense fQo��Phone <br /> TYPE OF WELL/PUMP: illi NEW WELL ❑ WELL REPLACE NT C7 DESTRUCTION O Out of][Service Well U <br /> PUMP INSTALLATION "❑ SYSTEM REPAI� OTHER O `storing Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP LINIE <br /> _.FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� <br /> n Industrial 0 Open Bottom O Manteca Die. of Well Excavation Dia. of Wall Casing <br /> pmastiC/Private O Gravel Pack O Tracy Type of Casing 5peciGcationa� <br /> tI M Public 1-1 i8ther ❑ Delta Depth,of Grout Seat Type of Grout <br /> I CI Irrigation �l Approx, Deplh ❑ a tarn 1 S rface_Seal Installed by <br /> III Repair Work Done U Typa of Pump SG��� H.P. 4 �o� Stats Work Done. <br /> f <br /> I Well Destruction ❑ Well DiameteSealing Material i Depth <br /> + Depth ��� Piller Material & Depth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION 0 LNa septic system permitted ii public sewer is <br /> available within.200 feet.l <br /> F Installation will serve:--Residence -Commercial-_,c,•.Other- " -'"`" ' - -r -- --•-rte <br /> Number of living units, JI Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water•table depth <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> r PKG. TREATMENT PLT. 0 Method of Disposal �l <br /> l Distance to nearest: Well Foundation Property Line. <br /> �l. <br /> LEACHING LINE f, 0 No. & Length of lines Total length/size �l <br /> ti FILTER BED,i. {1 Distance to nearest: Well —Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Sixs`y s" ' * -Number I� <br /> SUMPS LI D`Distance to nearest: Wel Foundation Z_­Property Lina l� <br /> DISPOSAL PONDS O <br /> t I hereby certify that I have prepared this application and-that the work.will be done-in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regutalions of the San Joaquin County <br /> s Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mariner as to become subject to workman's compensation laws of Cal4ornia." Contractor's hiring or sub`contracting signature <br /> r certifies the following: "I certify�I at in the performance of the work for which this parixlit ii issued, E shalt employ persons subject to workman's compenaa <br /> tion laws of California." " <br /> Thea lies t st call for aI I required <br /> pp J ,eq inspections, Complete drawing on rev es side. <br /> Sig d Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by I Date ` �p Area <br /> Pit or Grout Inspection by Ip Date Final Inspection by �--'rn �. I�. Date _25 19 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ` ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> ' + EN 13.20{REV. n Si elk ,d1] 1 <br /> EM 14'.20I �,ll C <br />