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APPLICATION FOR PERMIT IF- S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 00 o6a­s <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 W", <br /> (209) 468-3447 <br /> pSMIT EMIRES 1 YEAR <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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of San <br /> Joaquin County Public th Services. <br /> 11 � City. Lot Site/Acreage I <br /> Job Address <br /> ' . 1 <br /> . t K � � <br /> Owner's Name ' ` Address Phone <br /> Contractor Address - License No. Phone <br /> YPE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION'0 Out of Service well Cl <br /> PUMP INSTALLATION ❑, SYSTEM REPAIR ❑ OTHER [ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial C1 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. Well Casing <br /> U Domestic/Private ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> M Public 1-1 Other © Delta Depth of Grout Seal Type of Grout <br /> CJ IrriUation ,w. Approx. Depth ❑ Eastern Surface Seal Installed by 1 <br /> Repair Work Done 0 Type of Pump I H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material,&-Depth I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO " REPAfRIADDITION M 1DESTRUCTION (No septic system permitted if public sewer is <br /> t available within 200 ifeet.I I <br /> Installation will serve: Residence— Corrlmerciel_ 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.Cl I Method of Disposal' <br /> Distance to nearest: Well !Foundation Property Line f <br /> LEACHING LINE 0 No. & Length of lines °° Total lenLgth/size. ` <br /> FILTER BED 11 Distance to nearest: Well —' Foundation Property Line <br /> "� s <br /> SEEPAGE PITS I I Depth Size j Number_: <br /> SUMPS LI Distance to nearest: t Well ", Foundation Property Line <br /> DISPOSAL PONDS ❑ f` 'Y. + <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 F t I <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 compsnsatibis"iaw�bf`Cslilorriia." Contractor's hiring or sub-contracting signature <br /> certifies the following: -1 cenify 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 applicant must call for all'required inspections. Complete drawing on reverse side. <br /> Signed X Tr « ". xT '__✓Title: Y Owy IE <br /> Date' r <br /> �� -W t t <br /> FPARTMENT USE ONLY t " <br /> Application Accepted by __. - a+-^- t�qp Date t Area <br /> Pit or Grout Inspection by Date Final Inspection by —_ Date / ... <br /> '1 <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> d 445 N SAN JOAQUIN, P O BOX 2009, STOCXTON, CA'95201 �\ \ <br /> "^- w ... ..1. <br /> FEE MOUNT DUE AMOUNT REMITTED CK REC VED BY DATE PERMIT'NO. <br /> iNF C'ASH ,El <br /> EH 13.241REV,Irs51 r Q� "'r' ` �.y� ,`�. /j^"':.�. <br /> EH 14.2a �6 7(/ <br />