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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT-EXPIRES YE FROM DATE 15SU <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 <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Pu lic Health t3ervi ea. <br /> Joh Address - Ci Lot Size/Acreage _V <br /> JjL <br /> ffQs Name Ile Address Phone <br /> or N� C-1 steels€ o. Phone�� <br /> TYPE OF WELL/PUMP: NEW WE&V WELL REPLACEMENT n DESTRUCTION O Out Well U <br /> Monitoring of <br /> service <br /> well ❑ <br /> PUMP INSTALLATION C3SYSTEM REPAI OTHER ❑ <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 /> r Cl Industrial 0 Open Bottom ❑ Manteca Dia.'of Well Excavation lose. of Well Casing <br /> lo.bli' <br /> mestic/private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specificationsl'I Cl Other n Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation Approx. Dept ' =rI I anstern Surface Seat Installed by <br /> Repair Work Done a JJ Type of Pump -�J P. <br /> State Work Dona <br /> VVeII-Das- iuction"'�❑"`Well"D4meter � —.'f Sealing-Its-ter-sal-i-Depth <br /> Depth '� ' Filler Material i Depth V <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION-I.;1 REPAIRIADDITION i I DESTRUCTION t I (No septic system permitted if public sewer is <br /> _r F available within 200 feet.) �+ <br /> Installation will serve: Residence cial.__^� Other .� <br /> Number of living units; Number of bedrooms <br /> Character of aol to a depth of 3 feet: — Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No:Compartments <br /> II f <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance-to nearest; Wel Foundation Property Line <br /> LEACHING LINE ❑ No. 6 length of lines Total length/size <br /> FILTER BED Cl Distance'to nssrest:'` Well I Foundation Property Line <br /> SEEPAGE PITS It 'Depth Size Number <br /> ' SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 r <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 following: "I comity 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 Ca•anla.' <br /> Thea is at ca orI r inspections. Complete drawin on r;vlside. <br /> r <br /> SigJa-A ,,( <br /> Title: Date: A.16/� <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date ren Z r <br /> I <br /> Pk or Grout Inspection by Date Final Inspection b Data <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 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> INFO <br /> . EH f]-244REY.1/N 61 PP (Do <br /> 1� �— Z 2� l/ <br /> EH 14.26 1� �J <br />