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1 <br /> APPLICATION FOR PFs'R1dIT nc Aft � � , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION JUN 24 1992 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 9NVIRON., ,�EKTAL HEALTH <br /> v><R�Tm F7CT�TR s 1 YPERMIT/SERVICES <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 and Regulations of San t <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone # <br /> Owner's No Address =9� Y-2-i 4Contra77r4�— . Addres�d Lcense N - Phone <br /> rvice Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out Moonitoring Well <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ <br /> ____�^ <br /> -s:01STANCE TO NEAREST: S£PTIC�TANK _ SEWERLINESDISPOSAL FLD. PROP. LINEq - �"}pITSISUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br /> Specifications <br /> M Ind isl ❑ Open Bottom ❑ Manteca Die. of Wall Excavation <br /> Type of Casing -- <br /> ameatitlPrivate ❑ Gravel Pack ❑ Tracy Typo of Grout <br /> M Publics Il Other El Delta Depth of Grout Seal <br /> ri Irrigation ` ' T_Approx. Depth ❑ Eastern / Surface Seal Installed by <br /> Repair Work Done ^L] Type of Pump-4kdA--- H,P. �i - State Work Done <br /> truction... © Well Diameter <br /> Sealing Material & Depth <br /> Well Des <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION 10 REPAIR/ADDITION 0 DESTRUCTION CI (No sbpe'w system thin 200}Bstit'ed if public sewer is <br /> IIF <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of wit to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Disputa <br /> o <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line y } <br /> a,-»-LEACHING LINE Ll No. ffr Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 /> 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 /> to.workman's compensation af_Celifo[nia.'-Contractor's hiring or sub-contracting signature <br /> employ any person in such manner.as to become subject. <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 applicant or I required in�cfinns.-Gornplets drawing o r verse side: <br /> Signed <br /> Title: Date: <br /> " FOR EPARTMEfVT USE ONLY / <br /> Application Accepted by Dats <br /> r Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> 3 �Z <br /> Additional Comments: <br /> Y Applicant - Return ail copies to: SAN JOAQUIN COUNT.X PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN,-P O-BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C K5H RECEIVED BY ATE PERM17'NO. <br /> •r kNFO �/j(� <br /> p , EH 13.241REV.rlM51 <br /> EH 14.1a <br />