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F ' <br /> f � " <br /> APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN,. PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PFMIT EXPIRES 1 YEAR FR M DATE S <br /> (Complete in Triplicate) <br /> Application is hereby made.to Ban Joaquin county for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County blic Health Services. <br /> Job AddressQA"AUPQ& T&__ City�_q4) Lot Size/Acreage ��q} <br /> Phone + <br /> jqis Neme Address-cs <br /> n <br /> o� d ress nae No. Phone L <br /> TYPE OF WELL/PUMP: NEW WEL__ ❑ WELL REPLACEMEN ❑ DESTRUCTION ❑ Out of'Service Well ❑ <br /> 'MoPUMP INSTALLATiOf SYSTEM REPAIR ❑ OTHER ❑ LINE Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LI Industrial O Open Bottom ❑ Manteca Pia. of Well Excavation Dia. of Well Casing <br /> N*>4mastic/Private Cl Gravel Pack C1 Tracy Type of Casing_ Specifications ��- <br />_� Public El Other F1 Delta Depth of Grout Seal Type of Grout <br /> Ligation __App►ox. Dep , I I Eastern j urface Seal Installed by <br /> Repair Work done U Type of Pump H.P ` State Work do <br /> Well Destruction ❑ Well Dian*% - Scaling-Material ✓k Depth <br /> Depth Tiller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 I- 'DESTRUCTIONI I (No septic system permitted if public sewer is <br /> �....� R. .#..�..--- <br /> : available within 200 foot.) <br /> Installation will some: Residence____. Commircial— Other <br /> Number of living units: Number of bedrooms ! <br /> r Character of soil to a depth of 3•feet: t '' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f { Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ E Method of Disposal <br /> Distance to nearest:. Well Fouridstion Property Line <br /> I <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER-BED.. . ., - G],-dietanca-to nsarsit:i ,.a-Well-- Foundation •--� —3 —•Property-Line— <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Dietance to 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 /> k Home 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 taws 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 appli st call f ► fired i spe.ctions. Complete drawing on re se side. <br /> Sigma Title: Date: r <br /> ENT-,USE-ONLY 0 <br /> � Application Accepted by <br /> Date Z Area 0 <br /> t Pit or Grout Inspection by - Date Final Inspection by i Date is <br /> iE Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> h 445 N San Joaquin, P O Box 8009, Stkn, CA 95201 <br /> FEE AMOUNT OUE AMOUNT REMITTED CASH <br /> BY DATE PERMITNO. <br /> INFO <br /> i <br /> r . Im 13.24 4111m r r r sl �R � r O� ,S, C7 t� 13 z— 01 l <br /> EH 112e <br />