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L � � <br /> 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 /> PERMIT EXPIRES 1 YEAR FROM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. j1 /� <br /> Job Address , y 72,� �S' "" � City_�.e Lot Size/Acreage <br /> Owner's N <br /> e� Address Phone <br /> / <br /> Contractor 7" ( Address icense NyJV YJ PhoQd <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL RtfLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well O <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 /> n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> 1'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth / <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION KT REPATR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other l� <br /> Number of living units: _.._ Number of hadineims 3 <br /> Character of sod to a depth of 3 feet: Water table depth ✓✓✓ <br /> SEPTIC TANK O Type/Mfg Capacity 0eO No. Compartments <br /> IF <br /> PKG. TREATMENT PLT.O I / Method of Dispo.71 <br /> Distance to nearest: Well_ Foundation s Property Line =7? <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well �Q ,C Foundation_T " Property Line <br /> SEEPAGE PITS 11 Depth Size �?i�1 Number <br /> SUMPS LI Distance to nearest: Well Foundation Prope4 Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 sub-contracting signature <br /> certifies the following: "I certify 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 mus a for all requir i spq ions. Complete drawing on reverse side. <br /> Signed Title: 9,44a.— Date: <br /> FOR EP TMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by f DateFinal Inspection by f' ateg <br /> Additional Comments: 11 f ( «_ r �d <br /> Applicant Returhl ell copies to: San Joaquin County Public Health Services h­eS2_. <br /> Environmental Health Permit/Services <br /> r -- 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT C(Up" ti `�''''4iMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'N0. <br /> I/ V C'7l <br /> EEH 13-24 N 14-35 <br /> (REV.1/951 17/ 7 • l/ / "i r—� 1r / tJ �� <br />