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APPLICATION, FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r (209) 468-3447 <br /> } YEAR P-8-01LDA19 ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County foes 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 <br /> �Public <br /> �Health services. <br /> Job Address esZ -A-e city -' Lot Site/Acreage <br /> kownef's Nama - goI oAddress • �rl Phon(Z-o22 <br /> Contractor Address License No. Phone <br /> a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> k PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> r , <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL s OTHER WELL PITS/SUMPS _ <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> } F- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private .❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public C1 Other C1 Delta Depth of Grout Seal Type of Grout <br /> GI Irrigation �„n.Approx, Depth d Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. f State Work Done <br /> Well Destruction 0 Well Diameter sealing Material & Depth r_ <br /> Depth Filler Material ✓tr Depth lV�� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDiT10N M DESTRUCTION fNo septic system permitted if public sewer is <br /> vailable within 200 feet.l V <br /> Installation will serve:- Residence Commercial_... Other <br /> Number of living units. Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> .SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> f Distance to nearest: Well Foundation Property Line `1 } <br /> t LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Q <br /> I hereby certify that I have prepired 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 fallowing: "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 /> t certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa• <br /> tion laws of California." (� <br /> The applicant must call for all required inspections. Complete drawing on reverse side". ` <br /> Signed — Title: _ r !G/ <br /> Date: <br /> FOfLDEPARTMENT USE ONLY <br /> Application Accepted by Date r G Area / <br /> Pit or Grout Inspection by to Final Inspection by Date <br /> Additional Comments: <br /> ru <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 ` • <yd lq) <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMI?F"N0. ~" <br /> • EH 13.21 IREVFrinSJ <br /> EH:4.m �y - e& <br /> A 91«/n) �v a -� <br />