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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM D TE SUS <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. TThns <br /> Of <br /> application is made in compliancewith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations <br /> Joaquin•County Public Health Services. <br /> City Lot Size/Acreage -m <br /> Job Address <br /> / <br /> Owner's Name r Address Phone <br /> ► <br /> f Contractor a Address <br /> License No. 479f-o r Phone <br /> TYPE OF WELL/PUMP: N WELL C3W LL.REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well C1 <br /> -,� Monitoring Well ❑ <br /> PUMP INST <br /> ALLATION_❑ SYSTEM REPAIR,[] <br /> DISTANCE TO NEAREST: SEPTIC TANK j. SEWER LINES DISPOSAL FLD. PROP. LINE 2a T w <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (SII �Er <br /> V, ►� Dia. of Well Casing <br /> 0 Indir'strial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private JO Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public <br /> f"1 Other (� Delta i Depth of Grout Seal b Type of Grout "-� <br /> tI I Irrigation ___Approi' Depth I I Eastern Surface Seal Install <br /> Repair Work Done L3 Type of Pump H•P•i State Work Dane [ <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material i Depth v� <br /> Depth " Filler Material i Depth <br /> TYPE OMPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septtilable wsystem <br /> t�t�'ed it public sewer is <br /> avaInstallation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> ,y. t Water table depth <br /> Character of sok to q depth of 3 feet: <br /> SEPTIC TANK. 14 ❑''-Type/Mfg I Capacity No. Compartments �. <br /> PKG.-TR EATMENT PLT.6 ;W` ,� I Method of Disposal <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> �A <br /> LEACHING LINE '`F [1No. & Length of linea Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> A t <br /> SEEPAGE PITS J-1-1 ]- Depth ..M Sue Number <br /> SUMPS F LfDiatance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS F ❑ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> rules end regulations of the Sen 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 shah not <br /> ` amploy 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." .0.1 ' <br /> The applicant must call for all required insp p ons. Complete drawing on reverse side. <br /> Sigma_ , Title: Date: <br /> r _ • <br /> t -rfOR DEPARTMENT USE ONLY '15t <br /> Application Accepted by s Date ` Area �" 1 <br /> Pit or Grout Inspection by Date Final Inspection w Oats <br /> 1073 <br /> -_- j�11 <br /> Addhional Comments: 10 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE• AMOUNT REMITTED CASH RECEIVECKID SY DATE PERMIT NO. <br /> INFO. EH 13-'24IAEV.I/Aa Iwlzl <br /> � f®o �D�a <br /> Ett 14-M <br />