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APPLICATION FOR PERMIT <br /> JS(�� 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 <br /> ®Services.r7 <br /> Job Address ___T ,L A Y A4, "��, City "` "'{+� Lot Size/Acreage J / az" <br /> Owner's NameTJ �'iCe0,d o Address Phone <br /> Contractor �Y �' Address l Cs•X rLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR�k 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 CONSTRICTION SPECIFICATIONS <br /> C7 Industrial O Open Bottom O Manteca Dia. of Well Excavation __ Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Psck O Tracy Type of Casing_ Specifications <br /> Il Public 11 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump -Z-6- H.P. State Work Done e1 <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: J <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments \\� <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line C <br /> LEACHING LINE C1 No. 6 Length of lines Total length/size <br /> r. <br /> FILTER BED ❑ 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 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 must for all required ingmWns. Complete drawing on reverse side. <br /> Signed Title: Date: ' <br /> F R DEPARTMENT USE ONLY <br /> 24 ) <br /> Application Accepted by <br /> ^�x � Date "" �9 t_..— Area <br /> 0 <br /> Pit or Grout Inspection by Date Final Inspection by , in Date 0 <br /> Additional Comments: ny,41 czyj 5Z4 ? '" <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDK RECEIVED 8y DATE PERMIT'N0. <br /> RINFO r I <br /> . EN 1124INEV.1/ft 5) ►� � i> J S' �: �/ C r 1 ! <br /> EH 14-Z <br />