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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �� a <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 �� <br /> (209) 468-3447 d 3 1 9� <br /> GI R 1-IAN IOAQUIN COUNT), <br /> PERMIT UPIAES 1 YEAR QMl_PA2 1A�5 l8L1C HEA; Tfq SE V1C <br /> I (Complete in Triplicate) ENVfRo MENTAl _g <br /> I lFA�Ir7�,pjrg cl)ry <br /> Application is hereby made to San'Joaquin County for a permit to construct and/or install the work herein descried ' This <br /> application in made in c=Wliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> Services. <br /> Job <br /> Job Address ��`` r���- ���1 ���'�-'T�'--..— City Lot Size/Acreage <br /> Owner's Name _ Address Phone <br /> Cantrac, ddresf.� -� License Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Nell ❑ t <br /> PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE' <br /> FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia, of Well Casing <br /> U Domestic/Private 0 Gravel Pack. ❑ Tracy Type of Casing Specifications <br /> R Public (:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irtioation Apprbx, D'epth ❑ Eastern rf'co Seal Installed by <br /> Repair Work Done L3 Type of Pump �4— H.P, State Work Dona W <br /> II Destruction O Well Diameter Sealing Material i Depth r <br /> Depth f' Filler Material 4 Depth- <br /> TYDEPP SEPTIC WORK; NEW INSTALLATION Ll REPAIR/ADDITION I7 DESTRUCTION G INo septic system Wrrmitled if public sewer is <br /> I available within 200 feet.] <br /> Installation will serve: Residence— Commercial—rOther <br /> t <br /> Number of living units: Number of bedrooms - <br /> Character of soil to a depth of 3 feet: Witir-table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No..Compartmerfis <br /> PKG. TREATMENT PLT. ❑ ; <br /> _11­1Nfethiod of Disposal <br /> r Distance to nearest: Well Foundation Property Line: <br /> LEACHING LINE CI No. b LengthoIline Total length/size <br /> FILTER BED Ch <br /> "Distance to nearest:' Well Foundation T Prop rty Line- - <br /> SEEPAGE PITS I I Depth Size Number j <br /> SUMPS LI Distance to'nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 I. � <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 Sen Joaquin.,-County F <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 1 <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 /> a <br /> The applics mu for all require 'requirecLiA ons, Complete drawing on erse side. / { <br /> Signed Ti tie: _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by RDate Q Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Z <br /> Additional Comments: r _ <br /> Applicant - Return all copies to: S JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 85201 <br /> i <br /> INFOFEE AMOUNT DUE AMOUN�T^R�EM\ITTED �K If RECEIVED BY p'alTE PeAmrr NlO. <br /> . EH 43-741REV.s <br /> EH rnss 19A i,sr C-07 a"' �/ r 3G10C 46.0 l� T �Z ?Z ^�tp <br /> i440 <br />