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APPLICATION FOR PERMIT <br /> p t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> V\ PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made•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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. _ <br /> I�Job Address /r ri CityA) Lot Size/Acreage ' G <br /> j , C <br /> Owner's Name�L J1t���L�v JAI —�l(� Address Phone ' �JfD <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELLR PLACEMENT (1 DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O/ SYS EM REPAIR O OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES POSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUTlqdSPECIFICATIONS <br /> El Industrial O Open Bottom O Manteca Dia. of Well cavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack O Tracy Type of OsingN Specifications <br /> M Public Cl Other O Delta Dep"t�h b/f Grout al Type of Grout <br /> G Irrioation Approx. Depth d Eastern Surface Seal Install by <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSSTavailable within 200 feet.)REPAIR/ADDITION CI DESTRUCTION CI`(No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: . Number of bedrooms r< Z <br /> Character of soil to a dept"3 feet: A Water table depth7 <br /> /^ <br /> SEPTIC TANK [9' Type/Mfg Capacity1� _ No. Compartments <br /> PKG. TREATMENT PLT. 0Method of Disposal <br /> Distance to nearest: Well Foundation f, Property Line <br /> LEACHING LINE No. & Length of lines Total length/size Q_LO <br /> FILTER BED CI Distance to nearest: Well Foundation _ Property Line <br /> G <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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 /> tion laws of California." <br /> he applicant mu all for al requi inspgctions. Complete drawing on rev rse side /I, <br /> igned < Title: f �` Date: _42- <br /> ryF R DEPARTMENT USE ONLY <br /> Application Accepted by C'n`pQM� Date - res <br /> Pit or Grout Inspection by Date Final Inspection b Date0_ <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 BOX 2009, STOCKTON, CA 95201 <br /> IEEE MOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'N0, <br /> EN 7 .70 <br />