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APPLICATION FOR PERMIT 1 <br /> � .$AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> zq.x ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> gE"TT F IRES 1 YEAR ?M DATE ISSUE <br /> (Complete in Triplicate) ^ V.3p-C� 7 <br /> Application is hereby rmde,to San4Joaquin County for a permit to construct and/or install the work herein described. Thla <br /> application is vale in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules ,d Regulations of San <br /> Joaquin Count Public Health Services. <br /> City ` Lot Size/Acreage <br /> Job Addrsat <br /> phone �� <br /> Owner's Name ," `-'�' A dress <br /> Contractor - dress License N � b F'hont! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well {.l <br /> Monitoring well [3 <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEARIrST: SEPTIC TANK SEWER LINES . � —r- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE- " —TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-7l Industrial ❑ Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> Type of Casing <br /> - specifications 1 <br /> (` omestie/Private 0 Gravel Pack L7 Tracy g F <br /> 'Public :' 1-1 Other Cl Delta Depth of Grout Seal Type of Groui_ 1. <br /> Irrigation Approx. De Eastern Su ce Seal Enstalled by <br /> o. <br /> Repair Work Done U Type of Pump, H.P. to ork Don <br /> Welt Destruction O Well Diameter Sealing Material & Depth 1 <br /> Depth Y111er Material i Depth Z <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.0 -REPAIR/ADDITION M' -DESTRUCTION 0_INo-septic system permitted if public sewer is <br /> available within 200 }eetJ <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 -'❑ Type/Mfg Capacity No. Compartments I <br /> PKG. TREATMENT PLT. 0Method of Disposal - <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE 0 No. & Length of lines Total length/size l <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line . <br /> SEEPAGE PITS it Depth :'- Size, Number <br /> M SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS 0 <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, 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 of sub-contracting signature <br /> certifies the following: ­J 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 applic=tll required inspe t' s. Completedrawing_on_rsverae-si .Signed Title: . - Date <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date. �- - Area Z� <br /> Pit or Grout Inspection by " Date Final Inspection by Datel <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUHLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> i 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> k FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> EH 13-24 IAIY.,,ntSl pP Vis=°° s�- f 9 3!L# -F.7 335: <br /> EH 34.26 <br />