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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 Vill <br /> (209) 468-3447 <br /> PEBMIT 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 Z •S d Ol City �_� tA.Ot Size/Acreage <br /> Owner's Name . Phone <br /> Contractor Ut-V,�. Address 0 k —1 Z� License No. 11D Z�73 Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT I-A/ DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION G3-- SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK J010 SEWER LINES Q DISPOSAL FLO. /bb PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private Navel Pack O Tr Type of Casing Q VBG Specifications <br /> �ilblic Cl Other elta Depth of Grout SealQ� <br /> n_ _ - l,,.Tyr,,na-of Grout 424 H l <br /> G Irrigation Approx. Depth ❑ stern Surface Soul Installed by� W QQ24J" V` t! <br /> Repair Work Done U Type of Pump H.P. — 3 Stateork D e <br /> Well Destruction p/ Wall Diameter Z,SO '/ Sealing Material & Depth <br /> Depth Fitt— CA✓ �Q?jOt <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> r <br /> Installation will serve: Residence, Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of &oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Foundation Property Line <br /> LEACHING LINE C1 No. b Length of lines Total length/size <br /> FILTER BED I:1 Distance to nearest: Well Founds. Property Line 7► <br /> SEEPAGE PITSI I Depth Sire <br /> tuber 0 <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line N <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 �7 <br /> Home owner or lic ant's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ,any per n in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the lowing: "I ce fy that in the performanc the work for which this permit is issued, 1 shall employ <br /> tion laws California." P Y Persons subject to workman's compensa• <br /> The appl' ant mu 11 re r i p e drawing o aid <br /> Signed Title: ­1 �C' <br /> ._. Date: - <br /> . R, m <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date 1 <br /> +--a-�r� ` Area <br /> Pit oqLGrout spection by Date �—�/ Final Inspection by�f iDate 7 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQ IN COUNTY LIC H ALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES Cq S r 0�5 f / 6V e C 0 t cw <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 v <br /> FEE MOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMITNO, <br /> . EM 17.21 111EV.i <br /> �h — vo <br />