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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOB 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM 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. <br /> Job Address �� l� �` %� �•��L� �=? t City "' ^iv Lot size/Acreage _ <br /> i '�`�' /y/_"� r'v j , s ir' "� Phone <br /> Owner's Name���_� C t 1 � � __ Address �,.,�„ <br /> Contractor � I 1R q Address ✓ ��,�1'�'i � - !!'r- License NotZ' S 7:' Phone', <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well 0- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O Monitoring Well C-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK '� SEWER LINES DISPOSAL FLDt6fle PROP. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL t +s4 PITS/SUMPSi�la2� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial XOpen Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack O Tracy Type of Casing— Specifications <br /> rblic Cl Other ❑ Delta Depth of Grout Seat Type of Grout <br /> ylee�I i0ation •_.Approx. Depth 0 Eastern Surface Soul Installed by- <br /> t, <br /> y <br /> epair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth (� <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well Foundation_ Property Line <br /> LEACHING LINE CI No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size:e Numbsr <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 1 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 must call for all requir d inspections. Complete drawing on reverse side. e <br /> Signed�X ylj � '�� Title: s Date <br /> A, DEPARTMENT USE ONLY ^ t <br /> Application Accepted by Ofd t,Lpr'ykA �.-.. Date ��d���T Area <br /> Pit or Grout Inspection by Date Final Inspection by �av Date y <br /> Additional Comments: �� v "(, � / �l� 6 /�vvy, �O G �/ C l ��i _,,n_ <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 <br /> INFO AM UNT DUE AMOUNT REMITTED CASH CK 1 RECEIVED BY DATE PERMIT'N0. <br /> EH 14.28 IIIEV. i n Ol , 0­0B <br /> EH:e•2e <br />