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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in Triplicate) <br /> Applicstion 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 R t o f San <br /> Joaquin County Public Health Services. A / <br /> 9 <br /> Job Address �'- <br /> /t/ [ .D+'I . City 7>0 Lot Size/Acreage �a C <br /> �J <br /> Owner's Name Y d t3a_z (- 1 4) Address ` r �' -- Phone �a <br />[ Conlraclor !h Address ED A4111L Yca K94 � License No.,21'7-S 33 Phone �T <br /> k TYPE OF WELL/PUMP: _ _ NEW WELLA WELL REPLACEMENT DESTRUCTION ❑ out of Service We11 <br /> PUMP INSTALLATION'( S SYSTEM REPAIR ❑ OTHER © Monitorit5g Well E� <br /> DISTANCE:TO NEAREST: SEPTIC TANK 4 011L SEWER LINEDISPOSAL FLD. PROP.-LINE� <br /> L FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS &A <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA7 QNS zQ3 <br /> 0 Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestit/Private 0 Gravel Pack ❑ Tracy Type of Casing �1_ Specifications <br /> lie CI Other ❑ Delta Depth of Grout Seal ype,of rout <br /> t� <br /> � <br /> Err ation, You_.Approx. Depth Eastern SuAace Seal Installed by n <br /> pair Work Done U Type of Pump H.P. IS _.-._ Slate Work Done_ <br /> Wall Destruction 0 Well Diameter Sealing Material i Depth <br /> I _m <br /> Depth Piller Material i Depth _ <br /> TYPE OF SEPTIC WORK: -NEW'INSTALLATION❑ REPAIR/.ADDITION 0 DESTRUCTION M INo septic system permitted if public sewer is („ <br /> available within 200 feel.) <br /> Installation will serve: Residence— Commercial— Other <br /> f Number of living units: Number of bedrooms <br /> Character of soil to i depth of 3 feet: Water table depth <br /> i <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> i <br /> Distance to nearest' Well Foundation Property Line c <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br />` FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI 'Distance'-16 nearest:_ Well 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 cenifies 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 /> cenifies 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 <br /> compensa-tion laws of California." <br /> The applicant must call for all required inspections, Complete drawing on reverse side'. <br /> Signed Title: Date: <br /> i <br /> FOR DEPARTMENT USE ONLY ( / � <br /> Application Accepted by `l A��a L �,• �- Date Area <br /> Pit or Grout Inspection by Date / Final Inspection by Data t 6 <br /> Additional Comments: .,� G <br /> Applicant - Return all copieeito: . 3 JOAQUIN, COUNTYIPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2005, STOCKTON, CA 85201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DA_TE PERMII'N0. <br /> S h r <br /> EH 7{•Ie ILLO U — 'Y� D 3 <br />