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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95203 <br /> (209) 468-. 3 Ufa.p <br /> �ESHIT EXPIRE§, I YEARr8QM DATE ISSUED <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 made in couepliance 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 Z_ AA,, City t Size/Acreage <br /> Owner's Name Address Phone <br /> • contractori&t=:� sic Address fib—aflk &OFJAZ4= <br /> 307lc License No. U al Phon <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR i& OTHER C Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br />,...� ..�.. �.. �.T TFOUND'A'TION"''"' —AGRICULTURE-WELL— OTHER WEAL-*- --=—PITS-/SIJM S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack . ❑ Tracy Type of Casing Specifications <br /> 1 Public I;1 Other p Delta Depth of Grout Seal Type of Grout <br /> C1 Irrigation ,/ Approrr, Depth 0 Eastern /. Surface Seal Installed by �.. <br /> Repair Work Done Type of Pump .� _ H.P. State Work Done <br /> Well Destruction O Weil Diameter Sealing Material atr Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION M (No septic system permitted it pteblic sewer is <br /> t* available within 200 lest.) <br /> 'r Installation will serve; Residence Commercial = Other µ •- <br /> Number of living units: .' Number of bedrooms <br /> Character of soil to a depth of 3 feet: i <br /> Water table depth rill � <br /> SEPTIC TANK t E, '❑ Type/Mfg Capacity No. Compartments } <br /> PKG. TREATMENT PLT. C1 °! Method of Disposal <br /> Distance to nearest: Well Foundation'" Property Line <br /> LEACHING LINE C1 No. & Length of lines �- Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS 11 Depth Size Number <br /> LI_Distance to.nearest:_ Wall_ Foundation f" Property.line; <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordan%ewiih"iian"Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature comifies the following: "I certify that in themanq e wt k i-which this permit is issued,f-shail not <br /> employ any person in such manner as to become subject to workman's compensation low Calif ." Cor racior'17 fi:;. or sub-contracting signature Y <br /> certifies the following; "I certify that in the Performance of the work for which this permit' hall orepo '' 8 g p F <br /> tion laws of Celifornla." y personsAiiu$ject to workman's com ones- <br /> �Y sw <br /> The applicant must call fora required in(poctions. Complete drawing on rev rse side. T <br /> Signed Title: �. �_ Y <br /> , � Data: <br /> T x FOR'DEPARTMENT USE ONLY. . x� �A� /y <br /> Application Accepted by g t Date r�i Area <br /> Pit or Grout inspection by Date ► v <br /> Data <br /> Additional Comments: Final Inspection by <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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASM �r�.Y/�y DATE PERMIT'NO. <br /> r EH 17•24 IREV.rirs) ���� /� 6 �! -i' L G ! ' r� <br /> EH 14-26 �w ®f I--JEO. <br /> 1 <br />