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~� APPLICATION FOR PERMIT <br /> C6 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> TTOL/7�n L'7CpIRES 1 YEAR FROM DATE ISSUER ... <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 /> City 4 Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name <br /> Q Address <br /> License No. Phone <br /> Contractor Address <br /> 1�4 C �3 `�'1" � l 9 <br /> DESTRUCTION O Out of Service Well O <br /> TYPE 0 WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ OTHER O Monitoring Well C_1PUMP INSTALLATION R SYSTEM REPAIR <br /> j= <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> PITS/SUMPS _ <br /> POUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> 0 Industrial O Open Bottom O Manteca Dia. of Well Excavation Specifications - <br /> *pomestic/Private O Gravel Pack O Tracy Type of Casing <br /> M Public Cl Other O Delta Depth of Grout Seal <br /> Type of Grout <br /> C3 Irrigation Approx. Depth 0 Eastern Surface Seal Installed by , <br /> Repair Work Done Lam- Type of Pump <br /> H P OEM—_ we_ �2-= State Work Done ' <br /> Sealing Material i Depth -" <br /> Well Destruction O Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Ll DESTRUCTION Cl availableseptic <br /> within 200 feet.)rmitted it public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of &oil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK O Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT, Q <br /> Distance to nearest: Well Foundation Property Line -- <br /> LEACHING LINE ❑ No. ID Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS O <br /> t the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and tha <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 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 f r fil required insoct'ons. Complete drawingon a 7:L_ <br /> Signed .� Title: Date: <br /> F DEPARTMENT USE ONLY ' <br /> Application Accepted by <br /> i�iT� Date v Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: ENVIRONMENTALJOAQUIN OPUBLICUNTY HEALTH <br /> HEALTHDIVISIONPERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEECK RECEIVED By DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT EMITTED CASH 9 <br /> . EH 13.24IREV.ii0151 INFO Dv (2--16 -3 3 <br /> EH A-2e <br />