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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 O BOX 2009, STOCKTON, CA 95201 <br /> t <br /> I!ERMIT^EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2 ? �W44AO" (Complete in Triplicate) <br /> j Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in eoviiance vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ;r Job Address 1Uhf r y � �� 0'e"&d /iJ Vo -C=&.- ovAcakn2 <br /> / Lot Size/Acreage <br /> �(Owner's Name l 9"s��f (C�Sd_C!__L(C�Address u,"g, d A Phone <br /> VContractor Address License No. Phone \ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.r) DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR-0 OTHERitor� �r wQ� ❑ �'} <br /> r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES °DISPOSAL FLD. AQP, LINE <br /> I FOUNDATION AGRICULTURE WELL __L'_,-10THER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (E� <br /> Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications `�J) <br /> 11 Public Ia Other ❑ Delta Depth of Grout Seams Type of Grout <br /> - i I Irrigation _.Approx, Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Dept. <br /> Depth Filler Material i Depth —•. <br /> ITYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted H public sewer is <br /> available within 200 leet.l <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms r,= <br /> Character of soll to a depth of 3 feet: 4 Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4 <br /> LEACHING LINE CI No. 6 Length of lines Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propirty Line ~ <br /> SEEPAGE PITS 11 Depth -Size - Number f <br /> SUMPS LI Distance to nearest: Well Foundation ' Property Line `I <br /> ' DISPOSAL PONDS ❑ <br /> t I here certify that I have <br /> by fy prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ruies 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 /> 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 /> certifies the fodov Ing: 'Y conify 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 callf all r aired ins son omplete drawing on reverse side. <br /> Signed Title p Dote: <br /> !�EPART MENT USE ONLY <br /> 4 Application Accepted by0 Dats " �3 �(� Area <br /> w Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> _ 445 N San Joaquin, P O Box 2009, Stkn, CA 95261 <br /> p� - <br /> IN 4 AMOUNT DUE AMOUNT REMITTED SASH RECEIVED BY DATE PERMIT'NO. <br /> • EIS 1344 IREv.1 i n 6! II <br /> EH t4.7a .L <br /> I <br />