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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> _ PERMIT EXPIRE$ 1 YEAR ERN DATE IS5U� <br /> L $'•7 _ r" " (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 co*'liance with San Joaquin County Ordinance No. 49 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se vices. <br /> �Cysj 41 �"+� yl� .f !� OIL Ci /' Lot Site/Acreage <br /> Job Addrest- <br /> Owner's Narrtib` r Ur?► f r- ' � �'Address Phone <br /> ur <br /> ContraCI& <br /> 1_f7_S J)1i Addressg6epItr-, License N12112 4 Phone -S-5- /y <br /> TYPE OF WELL/PUMP: JIB NEW WELL ❑ WELL_REPLACEMENT ❑ DESTRUCTION ❑ Out of Service trail Cl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER © Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �F <br />{ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F� ndustriat ❑ Open Bottom ❑ Manteca Dia, of Wel! Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public (I Diit,her ❑ Delta Depth of Grout Seal Type of Grout �`•I <br /> M Ir6oation �NFApproK, Da 0 Eastern Surface SaUI Installed by <br /> Repair Work Done U . Type of Pump H.P. -J State Work Don Y�_ <br /> Sealing Material i Depth f <br /> Waif Destruction ❑ WeII�Diameter "1 <br /> Depth Filler Material i Depth ; <br /> TYPE OF-SEPTIC WORK: NEW INSTALLATION I) REPAIR/ADDITION T-7DESTRUCTIONGI INo septic system permitted if public sewer is <br /> available within 200 feel) <br /> Installation will server Residence- -Commercial— Other _4'' <br /> Number of living units: Number of bedrooms \tom <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ 1�ype/Mfg Capacity No. Compartments <br /> ? PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: -Well Foundation Property Line <br /> .w <br /> LEACHING UNE C1 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i'I Depth Size Number ` <br /> a SUMPS Ll 'Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 <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 masker as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the foil wing, "I certify:that in the perfor once,of the work for which this permit is issued, I shall employ persons subject to workman's compansa• <br /> tion laws of lifornis." �' <br /> The applica st call for required in ons. C plate drawing on rse side. �r <br /> Signed X Title: Date: <br /> I <br /> FOR DE ARTMENT USE ONLY <br /> Application Accepted by Date ,1 Area .2 �� Z,.� <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 h <br /> , i -ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �\ <br /> MI 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> IFEE NFO AMOUMT DIE AMOUNT REMITTED CASH K 4 RECEIVED By DATE PERMII'NO. <br /> s 1 <br /> . EH 13.24 IREV. <br /> EH 11-2e �i'_ <br />