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r 3 <br /> APPLICATION FOR PERMIT S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 N O W 19 '� <br /> (209) 468--3447 <br /> R <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 Stade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> X <br /> b Address I �Inol_J.� City t Size/Acreage <br /> wner's Name �� �.�f ��� Z-93-�00 <br /> LGddress C l ` 1 C (� Phone <br /> Contractor n l Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL p ELL REPLACE NT n DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTE EPAIR C1 OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER L NES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICUL REAELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom ❑ Manteca ia. of Well Excavation pia. of Well Casing <br /> U Domestic/Private C1 Gravel Pack 0 Tracy T e of Casing Specifications <br /> M Public I-1 Other p Delta De of <br /> Grout Seal Type of Grout <br /> ❑ Irrigation Approx. Depth L] Easta <br /> Surf S. Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Welt Destruction ❑ Well Diameter Sealing Material Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION CI DESTRUCTION fNo septic system permitted if public rower is <br /> available within 200 fest.} <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Wolf Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I Certify that in the perlormance 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 subcontracting 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." <br /> The appliMano, Cali for all required inspections. Complete drawing on rev a side. <br /> i <br /> Sned <br /> fl Title• �.lv�_t/� ` Date: <br /> 0 DE RTMENT USE ONLY G <br /> Application Accepted by I .. L Ck ADate Tl'�`(�����]� Area !! _J <br /> Pit or Grout Inspection by Date Final Inspection by Datsc�" ZU <br /> Additional Comments: <br /> 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 /> FEE INFO AMOU T DUE OVNT REMITTED CASH CKirRECEIVED BY GATE PERM-VNO. <br /> . 1H 43.24IREV.Iintl 7 � 1 (7v-LR17 <br /> EM 14.16 / c �� <br />