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APPLICATION FOR PERMIT <br /> �J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> V ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 4 P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT ESPIRES 1 YEAR FROM DATE I S <br /> (Complete in Triplicate) <br /> Application is hereby msde.to San Joaquin County for a permit to construct and/or install the vork 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 <br /> Public Health Services. ; <br /> XJob Address City"T A �1 � - City Lot Size/Acreage <br /> x Owner's Name Address .23-al E 91" S� Phone -q <br /> "`Contractor OCA Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC•TANK'~ ^'`" S R LINES SAL FLO. -PROP.-LINE.___, <br /> FOUNDATION AGRIC URE WELL OTHER,WELL PITS/SUMPS _ <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA C UCTION SPECIFICATIONS,,; <br /> Cl Industrial ❑ Open Bottom ❑ Manteca is. o} II Excavation Dia:of Well Casing <br /> f:l DornesticlPrivate ❑ Gravel Pack ❑ Trac Type of Ca' Specifications <br /> FI I.1 Public 1-1 Other _ Its Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx I I Eastern Surfac_e_Soul Installed by <br /> jRepair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms s <br /> Character of soil to a depth of 3 Water table depth <br /> SEPTIC TANK ❑ Type g s � „� No. Compartments <br /> PKG. TREATMENT PLT. ❑ '' a <br /> h Method of Disposal <br /> Distance Raw*:maAufl pirw,)ma4Qut Property Line <br /> LEACHING LINE L1No. b L },t oit Ines Total length/size <br /> FILTER.BED ❑ Distance t6 Irombll :la �a 0Property Line <br /> L <br /> SEEPAGE PITS •I I 'Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <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 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 /> Wn laws of Calif ata." <br /> The applicant t.call for 7011ftinspoptions. Complete drawing on reverse side. ~ <br /> xsigned Title. Date:"U <br /> 0-5OnF!SQkPARTMENT USE ONLY o, l <br />! Application Accepted byDate 1 Z Area Q ` <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin Box.2009FEE , 3tkn, QA 95201 <br /> F <br /> E-7 <br /> C <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT"NO. <br /> • EN 13.2 IItEV.rir♦6) ® <br /> EN 142E //// <br />