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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> D1;i IT IRIS 1 YEAR IrRDATr,, ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made•to $an Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin unty Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> a <br /> Lot Size/Acreage <br /> Job Address re <br /> City --- T <br /> Owner's Na w ✓/f r, (/1. ... Address el)� 6J7 `c v� s Phone <br /> ContractorL Address rZt <br /> License LVo, v� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F.1 DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR OTHER ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial O Open Bottom O Manteca 04. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing Specifications <br /> 0 Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Irrigalion Approm DDo th'LC�1 Eastern Surface Saul Installed by <br /> Repair Work Done Typo of Pump�ddOs�� H.P, State Work Dane <br /> Well Destruction D Well Diameter Seals liaterial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 :DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will tb►ve: Residence— Commercial.—_— Other t <br /> Number of living units: Number of bedrooms �1 1 <br /> Character of toil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Lini <br /> LEACHING LINE ❑ No. & Length of lines _. _ __-_.- Total length/size <br /> FILTER BED n Distance to nearest: Wall foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well ___ Foundation Property Line <br /> DISPOSAL. PONDS ❑ <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 workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify thot,in the performance of the work for which this permit is issued, I shall employ persons subject to workman's co pens&- <br /> tion laws of California." <br /> The ap ust NI for all required ' ctio : Complete drawing o se side. <br /> Signed Title: f Date: a <br /> �6 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �-� _C00 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTEO CK RECEIVED BY DATE PERMIT NO, <br /> INFO <br /> CAS H_ <br /> . EH13-24W V. 5S ILASrd� k2s �A.% <br /> Cit) <br /> EH i4_X <br />