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V <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '{ <br /> ENVIRONMENTAL HEALTH DIVISION . <br /> P O BOX 2009 STOCKTON CA 95201 ' : . <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work Fr� crud. ie <br /> application is made in ccupliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules mad no of flan <br /> Joaquin County Public Health Services. <br /> Job Address I Lot Sire/Acreage <br /> Owner's Name �.,� G �t'�— Addres -- Phone 'S <br /> Contract r 1� % �- ��`� i ense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAC ENT M DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPA A OTHER ❑ Monitoring Well <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 E L�PROBIEM AREA CONSTRUCTION'SPECIFICATIONS <br /> f-1 Industrial ❑ Open Bottom+ ❑ Manteca Dia. of Well Excivation Dia. of Well Casing <br /> ic/Private ❑'Grave! Pack 0 Tracy Type of Casing/ i Specifications <br /> M Public I_f Other D Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Devith 0 Eastern` Surface Seal Install <br /> x ! <br /> Repair Work Done U Type of Pum ZCK.P —J S at ork Q b n <br /> Well Destruction O Well Diameter Sealing Material i Depth S <br /> Depth �� / 1 } 'FfTlei MRterisl—i Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O 'REPAIR/ADDITION 0 DESTRUCTION CJ (No septic system permitted if public sewer is <br /> t available within 200 feet.1 <br /> Installation will serve: . Residence._ Commercial=F)!her�-r' <br /> Number o1 living units: Number of bedrooms <br /> :?a�, Character of soil to a depth of 3 feet: Water table depth r <br /> a <br /> SERTIC'-TANK Type/Mfg Capacity f No. CornArtments. Y <br /> PKG. TREATMENT PLT. 0?:1 Method of Disposal <br /> ;Distance Nto nearest: Well Foundation } Property Line <br /> i <br /> LEACHING LINE :C1 'No. & Length of lines Total length/size <br /> FILTER BED `i Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I le Depth Sire Number i�---` <br /> SUMPS hl Distance to nearest: Well Foundation k Property Line <br /> DISPOSAL PONOS ❑ - <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, ander <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the periormance'ofAhe,wofk 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." Contractors hiring oc sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell employ persons subjeci-to workman's compensa- <br /> tion laws of California." + s <br /> t <br /> *,1 ! "- <br /> ' i <br /> The appllc u call require inspections, Complete drawing on r=se . <br /> S ns -IXvkd <br /> Date: -1d <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by ' Data . /1 ` _ Araa <br /> Pit or Grout Inspection by I Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 85201 <br /> INFO FEE AMOUNT DUE AMOUNT ttEMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EN 14.2 IREV.+iMsi I�' r�3' /D 0 0 <br /> Ek',�•2e I / <br />