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af" 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 /> 4 <br /> PERMIT BUIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby m►de,to Sass 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 /> Jo"O" n County Public Health Services. <br /> i J <br /> 1 �Job Address � Cit Lot Size/Acreage <br /> Ownir's Nam Address Fin 11/0 16.17 - Phone �^ <br /> WY <br /> Contract ddres ! Wd.6 icense N0:9& �-' _Pho <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL L REPLACEMENT (=,1 DESTRUCTION ❑ Out of Service Well ❑ <br /> _ PUMP INSTALLATION 10 SYSTEM REPAIR 0 OTHER ❑ Mon�toring Well <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE; <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSYSUMPS h <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CQNSTRUCTION SPECIFICATIONS € J <br /> 0 Industrial ❑ Open Bottom , ❑ Manteca Dia. of Wall Excavation 1 Dia. of Well Cepinq r J' <br /> U Domestic/Private 0 Gravel Pack El Tracy TYPe of Casing Specification <br /> A Public [3 Other 1 q f ❑ Datta 4 Depth of Grout Seal. Type of Grout <br /> M Irrigation �.Aplxo><; Deglh" ❑ Eastern Surface Seal instgllod by `J <br /> Repair Work Done U Type of Pump H.P! " t State Work'Done_ <br /> Wall Destruction ❑ Well Diametir Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INST LLA ION❑ REPAIR/ADDITION DESTRUCTION CI (No septic stem ermined if obits s w r <br /> Ali P Y a s s <br /> �' _ P P I <br /> available within 200 fast.) <br /> Installation will serve: Residence Commercial Other • <br /> Numbtlr of living unil. �_ Number of bedrooms <br /> E Character of#011 to a depth of 3 lest: <br /> SEPTIC TANK Water table depth <br /> E�ype/Wlt� Capacity"� No. Compartments <br /> PKG. TREATMENT PLT. C1 Method o1 Disposal <br /> Distance to nearest: Well Foundation Proplrty[Line d <br /> LEACHING LINE No. IS Length of lines ngth/siz¢ <br /> FILTER BED C1 Distance to nearest: Well Foundation 3 PrPpany Line <br /> j <br /> -� <br /> SEEPAGE PITS 11 Depth Nu 60 <br /> SUMPS ` V-Distance to nearest: Well Foundation_ Property Lina <br /> DISPOSAL PONDS '❑ _f <br /> i 1 hereby cenify 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 regui¢tions of the San Joaquin County _ <br /> Home owner of 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 cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> I tion laws of California." <br /> The applicant must Cal} for all tequila .Je'jc lions. Com a drawing on reverse side. <br /> o <br /> DeEe: -_ <br /> FOR DEPARTMENT USE ONLY <br /> t ! <br /> Application Accepted by Date ..� `? Area <br /> Pit or Grout In{pection by Date Final Inspection by -�C�_ Date <br /> Additional Comments; <br /> Applicant - feturp all copies to: 9AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAH JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> 1fEE AMOUNT DUE NT REMITTED CASH RkEiVEO eY DATE PEAMIT'NO. <br /> + EM I�7�111EV,rirl6r <br />