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1 <br /> APPLICATION FOR PERMIT <br /> C� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ! <br /> P O BOX 2009, STOCKTW, CA 95201 i <br /> (209) 468-3447 <br /> jiPERMIT MOM I YEAR rR-OW-DATE. ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby madeto San Joaquin County for a permit to construct and/or install the work 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 Public Health Service <br /> Job Addrss �YU City Lot Size/Acreage <br /> Owner' me Address ` p V I Phon <br /> 5 d� <br /> Cont N A dress r �� License Phone <br /> TYPE OF /PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well <br /> PUM INSTALLATION ❑ SYSTEM REPAIR ® OTHER 0 Monitoring Well <br /> I DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia."of Well Casing <br /> U Oomssi ic/Private ® Gravai Pack 0 Tracy Type of Casing Specifications <br /> M Public (:1 Other IJ Delta Depth of Grout Seal Type of Grout <br /> 5 C� Irrigation —Approx. Depth I) Eastern Surface Saul Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth,' Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl REPAIR/ADDITION 0 DESTRUCTIO I lNo septic system permitted it public sewer is ! <br /> vallable within 200 feet.) <br />` Installation will serve: Residence Commercial— Other <br /> Number of living units: —4— <br /> jj Number of bedrooms i I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments s <br /> PKG. TREATMENT PLT, C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br />' LEACHING LINE C1 No. & Length of lines Total length/size <br /> 5 FILTER BED n Distance to nearest: Well Foundation Property Lina <br /> s <br /> SEEPAGE PITS 11 Depth Size Number 4 <br />.i <br /> SUMPS L1 Distance to nearest: <br /> Well Foundation Property Line <br /> E DISPOSAL PONDS ❑ <br /> 1 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 /> r <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 cern t the performance of the work for which this permit is issued, I shall employ mons subject to workman's compensa- <br /> tion <br /> om ensa• � <br /> �� Y (� p P Y Pe E P <br /> tion laws of California." a <br /> The applicant or 1 equi d inspections. Co 1 <br /> 6 drawin n versa s a. <br /> y Signed Title,17 J� �� <br /> DEPARTMENT USE ONLY <br /> Application Accepted by !` Data Area <br /> Pit or Grout Inspection by Date Final Inspection by G Date �a ' <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 O BOX 2009, STOCKTON, CA 88201 <br /> IN <br /> CK <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> u <br /> 1 . EH 17.24IREV. it$P 0 p� ��� �Fw . <br /> fm 14-20 <br /> II, / <br />