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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE <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 Slade in coa>piiance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address .. �� �UQ City Lot Size/Acreage <br /> Owner's Name n 0 Address f� � � Phone <br /> Contractor �t F-k, Address• /L .Z�9Tf/-�CLP License No.6A�5J{5-,_Phone TjXf <br /> TYPE OF WELL/PUMP: NEW WELL ❑ _ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER 0 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 WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wall Casing <br /> EI Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications <br /> Il Public C3 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I EaMern Surface Said Installed by <br /> Repair Mork Done U Type of Pump H.P. State Work Done � (y <br /> Well Destruction ❑ Wall Diameter Sealing Material i Depth <br /> Depth Filler Material li Depth a <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATIONX REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> �.' available within 200 feet.) <br /> Installation will serve: Residence-e-l"Commerciat_ Other <br /> Numb r of living units. _1_. Number of bedrooms <br /> Character of soil to a depth of 3 feet: ,4 Is 4xeg Water table depth <br /> SEPTIC TANK ❑ Type/Mfg L Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ R �r Method of Disposal <br /> Distance to nearest: Well� Foundation_. 2F Progeny Line .. <br /> LEACHING LINE Ve­lklo. b Length of lines iso• ` 4�,O Total length/sire <br /> §LTER BED 0 Distance to nearest: Well,1jS_J'c Foundation O F r Property Line .,l L0_-70'A= <br /> 1 <br /> SEEPAGE PITS �11 lhT Size Number <br /> SUMPS Distance to r4wast: Well Y_Q_.-Lr_� Foundation O"9`" Property Lina Zt2R <br /> DISPOSAL PONDS 0 <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 certifies 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 woikman's'compensation laws of Csfifornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenss- <br /> own laws of California." <br /> The applicant must call <br /> for sit squired inspections. Complete drawing on reverse side. ^� <br /> Signed X ` .4 -Title:_..:�_ - Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by . w Date Area 1� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> t <br /> Additional Comments: jeock jd6eE ; - 2- <br /> Applicant - Return all copies to: San Joaquin ounty Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San.Joaquin, P O Box 2009, -Stkn, .CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERM17'NO. <br /> . E11,3-24IREV.i R6) 4399 60 <br /> EH 14.29 <br />