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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONN[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 PA Y C,jV <br /> P O BOX 2009, STOCKTON, CA 95201 R CLZg , <br /> PERMIT EXPIRES I Y FROM DATE ISS M Af0V 0 9 1992 <br /> (Complete in Triplicate) <br /> SA+'UJC <br /> P P C NEA <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or insta];l'tkie�rrorkfyheseii� escrYptd This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the )lutes add I�egu1}tioxis�,o�fl�t3an <br /> Joaquin County Public Health Servic <br /> i <br /> Job AddressAZ City Lot Size/Acreage <br /> 1147-01 9-4,e-� <br /> Owner's Name Address ZL Phone <br /> Contractor Address <br /> 6 W. &0.LimLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT . DESTRUCTION Ll Out of Service well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ onitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. i PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ \ <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS { 4 <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> DomesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> f•1 Public Cl Other f"1 Deita Depth of Grout Seal ype of Grout <br /> Irrigation __Approxi Depth I Eastern S rface Saul Installed by 1 <br /> Repair Work Done L3 Type of Pump H.P. State Work pone �fl <br /> k Wall Destruction O Well Diameter f Sealing Material i Depth r <br /> Depth biller Material i Depth t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public rawer is <br /> available within 200 feet.) i <br /> Installation will serve: Residence_ Commercial a___ Other ` <br /> 1 _ <br /> Number of living units: Number of bedrooms <br /> I Character of will to a depth of 3 feet: Wate� table depth <br /> ` SEPTIC TANK O Type/Mfg { ' Capacr; i ! No. Compartments t <br /> PKG. TREATMENT PLT.0 _ .. - -Method of Disposal- - <br /> Distance to nearest: Welt Foundation _. Property Line ' jte <br /> LEACHING LINE Ll No. fk Length of lines _ _- - — -Total-length/size <br /> FILTER BED ❑ Distance to nearest: Welt Foundation Propirty Line <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation {� ,^v/ Property Line va <br /> DISPOSAL PONDS ❑ I i / 1 ; r <br /> ' I hereby cenity that I have prepared this application and that the work will be done in accordance with Sin Joaquin county ordinances, state laws, ander <br /> rules and regulations of the San Joaquin County # F <br /> i Home owner or licensed agent's signature certifies the following: "I certify tRat-in-the`performance"of'thirwork for which this psimit 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 tub-contracting aginature ��.. <br /> certifiesthe to :"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 <br /> The applica call for all r inapscf . C plate drawing on rev aside. I <br /> ' + *L <br /> Signed Title: <br /> Date: <br /> �•, j / 9_ R DEP L1L...__. <br /> • . <br /> Date` Area - <br /> Application Accepted by I i <br /> Pit or Grout lnspiretion by Date Final Inspection by�,(,b®� ��a�� ; Date <br /> t s <br /> Additional Comments: <br /> Applicants Return all copies to: San Joaquin County Public Health Services <br /> v Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 3 <br /> s <br /> FEE AlfOUNT DUE AMOUNT REMITTED I K R CEIVED BY ATE PAmi-r-NO. <br /> EEN 17.24 4REV.1!9 S, IN ! ` W� <br /> " <br /> EM 14-M <br /> I <br />