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.:F <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 96201 { <br /> (209) 468-3447 <br /> 9S 1 YEAR k 1Q9 DATE <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 k <br /> application is made in ccuiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> r0 f I D "(--- _ City S'LOL �� Lot Size/Acreage d % tI •— <br /> p� <br /> i^ <br /> Owner's Name <br /> 0AV!O � /L'.A/r� Address _ �p �a �7� A4 _ Phone ��f� `� <br /> ContractorLl <br /> 5 / Address License No. Phone i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION Ll out of Monitoring Well {.1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r d <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia, of Wel! Excavation Specifications <br /> (J Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing <br /> Cl Other 0 Delta Depth of Grout Seal Type al Grout d <br /> EJ Public # <br /> 0 lrrigalion —Approx, Depth C) Eastern 'Surlace 5eul installed by <br /> Repair Work Done L) Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter <br /> Sealing Material i Depth Q <br /> Depth Filler Material-& Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAIR/ADOITION CI DESTRUCTION CI (No septic system permitted if public sewer is <br /> ' available within 200 feet.! <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: � Number of bedrooms <br /> Character of*oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity D No. Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well ,� • Foundation Property Line /T <br /> LEACHING.LINE Cl No. 8 Length of lines. <br /> Total length/size �� Z.� <br /> FILTER BED n Distance to nearest: Well Foundations f z Property Line <br /> SEEPAGE PITS 11 Depth Size 3��f Number 7r <br /> Iperty Line <br /> SUMPS Cl Distance to nearest: Well �.:.�[_ Foundation Pro <br /> �� <br /> DISPOSAL PONDS ❑ <br /> k 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 cenifies the following: "I certify that ormance at the work for which this permit is issued, I shall not <br /> in the peri <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 /> i cartifies the followi 9 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 law Califor Ia." <br /> The apply m ust q for I quired inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> ©[,✓n/� Date: . / z 20_7 <br /> ��11EPARTMENT USI~ ONLY <br /> } Application Accepted by Date 1Z Area <br /> ! � <br /> Pit or Grout Inspection by Date _ Final inspection by Data �0 <br /> Additional Comments: <br /> t <br /> f 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 95201 <br /> i FEE AMOUNT DUE UNT REMITTED CASH HECEEVEO 8Y DATE PERMITNO. <br /> f INFO [� 9f }�}'`C/air} <br /> • EH 13.24 IREV,I/A51 `t 1 �r!' r _ �O R - <br /> EN 14'26 <br />