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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �qJr SQM r <br /> VPHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PWIMIT EXPIRES 1 YEAR FRAM DATE ISSUED <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 OV . f� ,City Lot Size/Acreage <br /> C� a�f�,�..� ress �rJ�S gj h <br /> Owner's Nameone <br /> Contractor ddress� a License No. Phon7�1-1,8 <br /> TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT I"1 DESTRUCTION Li thtt of ervtce well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ #L,6)-;X45OTHER '�� ?.Monitoring Wel]j <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL `PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ! (TENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOVS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Exccaav�a/tion Dia. of Wail Casing . <br /> LM <br /> f.l Domestic/Private iravel Pack L7 Tracy Type of Casing�CJSp ciGcations_.. <br /> f'I Public Cl Ottyer 1-1 Delta Depth of Grout Seal I A,uem ' <br /> I I Irrigation TOApprdx. Depth I I Eastern Surface Saul Installed by 4 16's <br /> Repair Work Done 0 Type of Pump AIA - M.P. State Work Oone „ <br /> Well Destruction ❑ Well Diameter _ Sealing Etaterial & Depth _ AIA <br /> DepthAfiC' Filler Material & Depth AZA <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 lee[.) <br /> - <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 teal: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 1 Method of Disposal r� <br /> Distance <br /> to nearest: Well Foundation Property Line �✓ <br /> LEACHING LINE 0 No. & Length of lines Total lengthtsize <br /> FILTER BED {:I Distance!to nearest: Wel! Foundation Property Line D <br /> SEEPAGE PITS I I Depth ..i Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS CI I y <br /> 1 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 1rrot� <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting Signa V. <br /> e , <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 compen5a- <br /> tion laws of Cali rnia." ' l hG !, +T <br /> The applican mus call all required' s tions. Complete drawing on reverse side. 11 S q /� <br /> Signed X Title: te: <br /> FOR DEPARTMENT USE ONLY 4 <br /> Application Accepted by Date r 0 Area <br /> r <br /> i <br /> Pit or Grout Inspection by Date 7 Final Inspection by Data <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies to: Ban Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Sox 2009. Stockton, CA 95201 <br /> FEE INFO mAMOUNT DUE AMODU/NQT REMITTED CASH REC E 8Y CK 97 DATE G'l PERM17'NO.. <br /> EH 13.14[REV.t/K51 `�g! 00 4 G/ `00 ��� `7 `�V 7tJ ya- i 1� <br /> EH A.2a <br />