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�l 5 <br /> APPLICATION FOR PERMIT 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION � � .� s� �ly��� �:' r� R <br /> P 0 BOX 2009, STOCKTON, CA 95201 s <br /> (209) 468-3447 APRT <br /> �t7N <br /> SIT, XMI89S 1 YEAR ROIL DA`E ISSUED PkL �i EN r AL HEALTH !, <br /> (Complete in Triplicate) yR.MIT/SECES � <br /> Application In hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is toads in compliance with San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address D� "" ." City Lot Size/Acreage <br /> Owner's NameT4. s Address -_ _ _ _ _ _ Phone <br /> Contracto ; � Address f 44c:F6-7',�©- 9-!r3 0451 License No. 26'I Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well G <br /> PUMP INSTALLATION P____ '" SYSTEM REPAIR L!-' OTHER ❑ Monitoring Well C7 <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 /> CTrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 4 <br /> sticlPrivate Cl Gravel Pack <br /> Z ❑ Tracy Type of Casing Specifications <br /> ❑ Public �°" a i71 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation , Approx, Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done,"6.-__T_ype of Pump t H.P. State Work Dona <br /> Welt Destruction ❑- Well Diameter Sealing Material i Depth <br /> Depth=—­_ _ „_Filler_Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JD REPAM5l O (TION CC DESTRUCTION CI (No septic system permitted if public sewer is �� k <br /> available within 200 feet.) <br /> Installation will serve: Residence_ 'Commercial— Other , <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: Water table depth t <br /> SEPTIC TANK ❑ Type/Mfg „ Capacity No. Compartments { <br /> PKG.--TREATMENT PLT. Cl Method of Disposal <br /> a Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. G Length of lines Total length/size <br /> FILTER BED 171 Distance to clearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number fQ <br /> Y SUMPS_ w �;,.LI -.Distance to nearest. We1f pb 4= �---Fo'undation- � Pro '-- - .�-_� ., <br /> DISPOSAL PONDS ❑ Party Line�-- <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:d <br /> e <br /> employ any person in such manner as to become-subject-do-workmen's-comperssatiorrltiw"f California."Contractors hiring of sub-contracting signaturey <br /> certifies the following; "I certify ttFat in the pertofmance of the work for which Ihis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call f e aired i <br /> q pettions. Complete drawing on reverse side. <br /> •�'z a <br /> Signed Title- �� �g <br /> Date: , <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �/ Area <br /> Pit or Grout Inspection by Date Final inspection by 2to <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 2008, STOCKTON, CA 98201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH` RECEIVED BY DATE PERMIT NO. <br /> • EH 1]•211IREV,I/+tSY <br /> EH t�.14.211v A* ;V`; /elyo FYI" <br /> r <br /> f I ' <br /> t <br />