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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION N 0�0 C <br /> c-�,, <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ma N1 <br /> 2=11 EXPIRES 1 REAR PM--DATE ISSUM <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 caEPliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. / <br /> Lr E- City Lot Size/Acreage <br /> r Job•)dd j ss LSHOP �7 i i <br /> ,,� -�ry 7Plhone <br /> Y"Owner's Name Address <br /> Conlraclor Addres j cense EVo: -- -Phone <br /> `TYPE OF,WELL/PUMP: .. NEW WELD 0 WELL REPLACEMENT C7 DESTRUCTION 0 Out of Service Hell ❑ <br /> PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER iO �� Monitoring well L7 <br /> DISTANCE TO'�kEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' <br /> FOUNDATION -AGRICULTURE WELL OTHER WELL. PITSISUMPS �. <br /> I INTENDED USE' ; TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIE iAT104S <br /> fl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 9?Dia. of Well Casing <br /> U Domenic/Private G7 Gravel Pack C]-Tracy Type of Basing Specifications <br /> �M Publics 1.1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 tfrr cation I '`Approx. Depth El Eastern Surface Seal Installed by <br /> Repair Work Done U Type of,PumpH.P. - ,4tate Work Done <br /> Well Destruction © Well Diameter T t Sealing Material &-Depth <br /> Depth <br /> Filler Material & Dep � <br /> 1 Depth -- <br /> TYPE OFiSEPTIC WORK: ANEW INSTALLATION JO REPAIR/ADDITION Cf DESTRUCTION -INo septic sysl�,ggm permitted if public sewer is <br /> I available withiK 200 feet.l��'' fo <br /> � <br /> Installation will serve: Residence_A, Commercial— Other <br /> (Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth l� <br /> ,SEPTIC TANK.. ❑ Type/Mfg Capacity — No. Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> �y. i <br /> LEACHING LINE C1No. & Length of lines Total length/size t <br /> FILTER BED I Distance to nearest: Well Foundation Property Line <br /> I t <br /> i SEEPAGE PITS [ I Depth Size Number <br /> 4t SUMPS i Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> `I hereby comity 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 /> r'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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the worst for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> lion lows of California." <br /> I The applicant . at cal for all req d nspecfl ns.r Co to drawing on reverse side. <br /> Signed <br /> f FIZNDEPARTMENT USE ONLY R M <br /> t LL <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date—.Final Inspection by a Date 1.F <br /> r Additional Comments: - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> t 995 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. <br /> INFO CASH <br /> .`EH1Y24IREV.rins 7Tlk4'r3o �U t_ fyw),- ��.�j•q y <br /> EK 14.25 1 "l 1 <br /> s <br />