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Nk <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION r <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM T E%PIRES 1 YEAR FROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby, made,to san Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cempl c with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public He t�i�fcea. <br /> Job Address P, CitySG[t1t?6't Lot Size/Acreage <br /> Owner's Name �t^ $ t Address p t f Z Phone <br /> Contractor Address ' License No. R Phone �� ! <br /> TYPE OF WELL/PUMP: a, NEW WELL [D WELL REPLACEMENT n DESTRUCTION 0 Out of Service well 0 <br /> { PUMP INSTALLATION O SYSTEW REPAIR 11 OTHER ❑ <br /> Monitoring Well 0 <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 /> 0 Industrial ' 0 Open Bottom .� Manteca - Die. of Well Excavation Dia. of Well Casing <br /> J Domestic/Private 0 Gravel Pack ,0 Tracy+- Type of Casing_ Specifications <br /> I'1 Public n Other fl Delta �.Depth of Grout Seat Type of Grout i <br /> I I IrfiUation :Approx. Depth" I I Eastsrn Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump ' H.P. State Work Done <br /> Well Destruction F0 Well Diameter # ���iriwl�i Depth <br /> Depth 's ' *';Filler Material i Depth <br /> TYPE OP,SEPTIC WORK, NEW-INSTALLATION .REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer}is <br /> available within 200 feet.l ' <br /> Installation will serve: Residence Commercial.— Other. R., ' ,•ti, <br /> I� Number of living units: Number of bedroom I .r <br /> Character of salt io,a depth of 3 feet: Water tabic depth (� <br /> SEPTIC TANK. �TType/Mfg <br /> L- Capacity� No. Compartments \t } <br /> PKG.TREATMENT PLT.O`, f r Method of Disposal <br /> Distance to nearest: VWell S�Foundation Property Line L46 -- . <br /> ' <br /> LEACHING LINE No. 8 Length of;lines Total lsngthlsize D <br /> 1. ��,� <br /> FILTER BED ,�" 0 Distance to nearest: Well�oundstion _ / K Property Line 4O_ <br /> SEEPAGE PIPS 11 Depth f l _Sire I Z Number <br /> SUMPS s b party Line <br /> iP9 1vr <br /> ISPOSAL PONDS 0 -,,, .. 3, <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 ;��PP <br /> Home owner or licensed ant's signature certifies the following: "i certify•that in the performance of the work for which this permit is issued, I shall n <br /> agent's <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for whichihis permit is issued,I shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> R DEPAOT0 <br /> NLY <br /> t <br /> Application Accepted by Data rea I <br /> Pit or Grout Inspectionby Date Final Inspection b YDate <br /> } <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Pubile Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2005, Stkn, CA 95201 <br /> I FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO, <br /> INFO41, <br /> {� r EH 13-74(REV.lint) � r r[�� e A e <br /> FH 14.7e <br /> 1 <br />