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. APPLICATION FOR PERMIT <br /> x SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICFBR E C E I 111'E D <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �„, F 0 BOX 2009, STOCKTON, CA 95201 SEP 3 Q 1992 <br /> (209) 468-3447 <br /> AbU ENVIRONMENTAL HEALTH <br /> YEAR PERM ITJSERVICES <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 cotWliance with San Joaquin County Ordinance.No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. f <br /> Job Address 7 6v City t Siae/Acreage <br /> Owner's Name es(—b " Phone <br /> Contract <br /> resR'- �la " �/-5- ansa N �Phone <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C3Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK._---- - SEWER LINES DISPOSAL FLD.-- ,PROP.:-LINE=-_- y <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Indusiriil ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing (} <br /> omestit/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications xV� <br /> 1Wf Public 11 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 Irboation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. dnk�- State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material A Depth <br /> Depth Filler Material A Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION L1,..DESTRUCTION C.I.fNo septic system permitted if public sewer is <br /> i —%-� available within 200 feet.) <br /> Installation will serve: Residence— Commerciat"`1 110ther-'-f- ' —LL <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: x Water table depth A <br /> SEPTIC TANK ❑ Two/Mfg } Ir �i Capacity. _- _- No. Compartments <br /> PKG. TREATMENT PLT. Cl ' r r Method of Disposal <br /> Distance to nearest: Well Foundation — Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER'SED h n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property line <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 persona subject to workman's compensa• <br /> tion laws of California." <br /> r <br /> The applies r all required in ions. Complete drawing on to a side. <br /> Signed Title: Date: <br /> DeARTMENT USE ONLY -7 <br /> Application Accepted by iGa..� � ��IIs... ` ___ Date A►eaL <br /> Pit or Grout In 7� <br /> apection by �' Date Final Inspection by Date <br /> Additional Comments: _ <br /> Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 B 008, STOCKTON, CA 85201 <br /> INFO <br /> FEE DUE A OUNT REMITTED1,1 CK IJ 8iE EIV O By hDATE PERMIT'NO, f <br /> . EH t3-7l1HEV.rin5J c0� ' ' /^/ <br /> It— <br /> [H 114-M /d/�/ <br />