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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> . � ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby vada 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. -�f/J <br /> Job Address S v�j E l "rp/t[ L/ C_'tiv TG Mt Site/Acreage <br /> Owner'sName / ddress 10(/ier/14I�Br hone <br /> Contractor •Sdress g;? D AW114-�p�License No." ,f/d Phone <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT 0 DESTRUCTION XVOut of Service well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 0TH ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Typo of Grout <br /> U Irrigation Approx. Depth ❑ Eastern, Surface Soul Installed by <br /> Repair Work Done U Type of Pump. H.P. Stats Iork Done <br /> Well Destruction A Well Diameter SeAling.Material E Depth <br /> Depth 3;EPiller Material•& Depth a r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION CJ 1No septic system permitted if public sower is <br /> - available within 200 feet.) <br /> Installation will some: 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 O Typa/Mfg. _. _ ___ Gap"rty __. . __ him-£omparernt$is <br /> PKG. TREATMENT PLT,C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS If Depth Site 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, ant <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,cdnify 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 spplicsn equir . Complete drawing on reverse ids; <br /> Signed Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by - Cwlw %A Aft DateyZ ��" Oil) Area ' <br /> Pit or Grout Inspection by Date Final Inspection by�� Data �a 0 <br /> Additional Comments: <br /> Applicant - Return all copies for SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED I t:ASW RECEIVED BY DATE PERMI-r'NO. w <br /> . _T F <br /> EH 1J•24 111EV.iiAsr {Q� Q� � <br /> EH;x•20 <br />