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APPLICATION-FOR PERI[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009 STOCKTON, CA 95201 <br /> (209) 468-3447 ® f�f� - �- <br /> PEMIX EXPIRES 1 MBAR ROY A <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address"-` "City Lot 81te/Acreage <br /> Ovrner:e Name <br /> Addresi <br /> eJ ✓/�/s tton t <br /> —3 <br /> Contractor ,y � - A d �-= ��`" License No. �6� Phone <br /> TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑. DESTRUCTION 0 Out of Service We11 0 y <br /> PUMP INSTALLATION,k'j4 SYSTEMAIR El OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK �SEWER LINES DISPOSAL FLD. PROP. LINE Q., <br /> FOUNDATION AGRICULTURE WELL` OTHER WELL == PITS/SUMPS <br /> INTENDED USE TYPE OF WELL., -f PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom �t ❑ Manteca Dia. of Well Excavation Dia. of Well Cssing <br /> Z4 OQ, <br /> ''Domestic/Private AGravel Pack.� -❑Tracy TM Type of Casing Specifications <br /> M Public is Other ❑ Delta Depth of Grout Seal Type of Gr <br /> rrigatiort Approx. Depth ❑ Eastern S}rrfacs Seal Installed by " <br /> Repair Work Done U Type of Pump H.P. © rf -State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Haterial i Depth <br /> t �.. <br /> ,.�_ ,- .� ---.-�pfh-:,.•.�•.--. , - "Piller"Materiel&"Depth <br /> t` TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION CI lNo septic system permitted it public sewer is <br /> available within 200 loot.1 <br /> Installation will serve: Residence Commercial— Other" F <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 loot: Water table depth <br /> SEPtIC TANK. ❑ Type/Mfg Capacity` No. Compartments <br /> PKG. TREATMENT PLT. ❑ � <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Linert <br /> i <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED EI Distance to nearest: Well Foundation Property Line ° <br /> _ I <br /> SEEPAGE PITS 11 Depth Size Number 1 <br /> SUMPS Ll Distance"tri"nearest: Well-- .r Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "1 certify that in the performance of the work for which this permit is issued, I shall no <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: -1 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 s aler requir s, Complete drawing on reverse idIL. ,r <br /> Signed itle. �� �� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ������ Area <br /> 4 <br /> Pit or Grout Inspection by Date Final Inspection by'" _ _Date. <br /> Additional Comments: - <br /> --'Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ <br /> ENVIRON TAL- HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SXJOAQUIN, P 0 BOX 2009, STOCKTON;'CA 85201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CX If GASH RECEIVED BY DATE f ERMIT"N_O. <br /> 017 <br /> f Est^a7s �/7 I <br />