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APPLICATI01 FOR PERMIT - t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r ENVIRONMENTAL HEALTH DIVISION -_ <br /> A A 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address . . `"• CityZ/� Lot Size/Acreage/V <br /> I <br /> Owner's Name Address Phone 5 <br /> Contractor L WV61 � Arddress.._49�w a License No. / Phone <br /> i <br /> TYPE OF WELL/PUMP: NEWWELLX WELL REPLACEMENT O DESTRUCTION 0 Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESr< f-- DISPOSAL FLO. LPROP. LINE <br /> FOUNDATION:�� AGRICULTURE WELL/1,0_100 WELL ITS/SUMPS40. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I-] Industrial O Open Bottom O Manteca Dia. of Well Excavation 6 Dia. of Well Casin �� \ <br /> )<Domestic/Private O*Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> irrigation —Approx. Depth I I Eastern -Surface Seal Installed by v <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <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 I DESTRUCTION I I INo septic system permitted if public sower 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. O Type/Mfg " Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING LINE Q No. 6 Length of lines - Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation- Property Line <br /> ` � E <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats 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 workmen'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 compenss- 1 <br /> tion laws of California." 1 <br /> The applicap. st call at squired inspections. Complete-drawing on rAwayse side. <br /> SignedJ W 4 - Date: ./ <br /> R DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by f Date Area ,k "f\' ' _* <br /> Pit Grout 1 tan by DateSFinal Inspection by Date_ <br /> Additional Comments: 6t�117 / d -+ Ott.. rLer- r.rePo +� <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 /> IFEE <br /> AMOUNT DUE AMOUNT REMI ED CASH ECEIVED BY DATE PERMIT'NO. <br /> . EH1}24 1REV.V a 51 <br /> EH 1426 13 <br /> .- .i <br />