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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 YE1W FROM DATE U I <br /> (Complete in Triplicate) <br /> Application is hereby —A -to son Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in catapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 1 <br /> City�10c �-- Lot Site/Acreage <br /> Job Address dd f/ <br /> Owner's Name CZ 6 L) ty 7T 0 Address Z3 0 c IFf G Phone S <br /> Contractor 0 hJ p A I Ll.AAddress 1,� T' 14 N icense No, /�/�� Phone <br /> TYPE OF WELL/PUMP. NEW WELL,;& WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> Monitoring 41e11 <br /> DISTANCE TO NEAREST: SEPTIC TANK L_ SEWER LINES 1_5�r DISPOSAL FLD. N4& PROP. LINE a r <br /> FOUNDATION p AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2�!f <br /> ,fJ-Industrial 0 Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private Gravel Pack C] Tracy Type of Casing__ Specifications <br /> I'] Public n Other pelta Depth of Grout Seal ?I = _ Type of Grout C <br /> ram rwi— <br /> I 1t Gr/ <br /> ! I Irrigation 6.5--f Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done �1 <br /> Ir lam+ <br /> Well Destruction O Well Diameter Sealing Material i Depth [ fJ <br /> Depth Sri Tiller Material & Depth r}v{} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION l I DESTRUCTION I 1 1No septic system permitted it 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 soil to a depth of 3 feat: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. 6 Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 foBowing: "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 /> The sppficant 1%1 all for al required ' speptions. Complete drawing on to arse ids. <br /> signedTitle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by vlf Date ZA9 Area If <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <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 40, <br /> f FEE AMOUNT DUE AMOUNT REMITTED CtW P4CEVJO BY DATE PERMIT'NO, <br /> E4F INFO A <br /> . EN M241IIEV. /„s! <br /> EN 14.30 ��✓✓ /' <br />