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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION <br /> .. 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT IRES I YEAR FRQM D E <br /> .- <br /> f (Complete in Triplicate) 17YS' f2 <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> in County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in compliance with tion Joaqu <br /> Joaquin County Public Health Beryl a. i3 <br /> 2 � r City Lot Size/Acreage . <br /> Job Address t � <br /> Address <br /> # -Address- <br /> ? <br /> Ownei i Name - <br /> r� `/ Z <br /> r Phone t <br /> Contiactor fess - �V License No. <br /> i TYPE OF WELL/PUMP: -NEW WELL ❑ WELL REPLACEMENT ] DESTRUCTION ❑ Out t4onitoring Well I lll ❑ t <br /> PUMP�INSTAL-i-ANON-O .� a SYSTE REPAIR ❑ OTHER ❑ ❑ <br /> 'OIST NCE:TO,NEAREST M SEPTIC TANK SEWER LINES ISPOSAL FLD. PROP. LINE <br /> i s + FOUNDATION'f AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F <br /> S <br /> _-JN TENDED.USE -- _TYPE OF WELL 4`` PROBLEM AREA ,CONS CTION SPECIFICATIONS <br /> Cl Industrial ; Open Bottom <br /> —0-Manteca D' . of II Excavation Dia. of Well Casing. <br /> Type of asin <br /> Specifications <br /> Doms`suc/Private �❑ Gravel Pack____ ._O-Tracy g <br /> `- ,- fl,Othei t ,-,I n Delta Depth Grout Seal Type of Grout <br /> `�1.Piltrlic I r- <br />[ I.Nirrigation A�prox Depth t 1 Easter Suda Saul Installed by _ { <br /> 'Repair Work Done ❑ Type of Pump H.P. State Work Done_ t__ <br /> Sealing Material i Depth <br /> I Well Dlistruction ❑ Well Diameter . <br /> y a Filler Material i Depth YAC I <br /> Depth , <br /> P OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION i I DESTRUCTION I I (No septic system peirhitted if public sower is <br /> TYPE r within WIZ, <br /> available w t <br /> fInstallation will terve: Retidertce Commercial that <br /> Number of living units: Number of bedrooms <br /> { < ~ Water table depth <br /> Character of loll to a depth of ifeeti` - - <br /> ( SEPTIC TANK. ❑ Type/Mfg >S ZU No. Compartments l <br /> { �1 PKG. TREATMENT PLT.-0 l Method of Di I ] <br /> 1 �► t Distance-to nearest:. Well . Foundation Property Line 1 y <br /> h 1 <br /> t- <br /> �' LEACHING LINE .rte No. b Length of linea T al lengthlsize <br /> FILTER BED ❑ Distance t6 neareat: Well Foundation Property Lista , <br /> SEEPAGE PITS I I DepthSirs ��oun <br /> n' r <br /> I <br /> SUMPS Ll Distance to near t: Well dstion Property Line <br /> ' DISPOSAL PONDS ❑ <br /> —,--1 iiiie -certify.-that-i-have_prepared�this_application_and_that„the work wilLbe-done_in_accordance_with_San.Joaquin.county-ordinances,-state-taws; and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must 11 for all r uir spsction Complete drawing on reverse side. , <br /> • f <br /> Signed Title: Date: <br /> -FOR DART SE ONLY <br /> x Application Accepted by Dais T [ Area <br /> �� ate <br /> �or Grout Inspection by4/ Z Date ?Final Inspection by <br /> Additional Comments: <br /> ',r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CEIVED°BY DA t? PERMIT'NO. <br /> INFO <br /> ♦ EH 1124 IFIEV.V/N 51 / gl y� <br /> Ell 11 2a <br />