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APPLICATION FOR PERMIT <br /> SAN JOAQUIN <br /> ENVX <br /> ENVIRONMENTAL HEAHEALTH <br /> SERVICES µr <br /> 4 P O BOX 2009, STOCKTON, CA 95201JAN 2 ?N <br /> (209Y468-3447 <br /> i. ENVIRONmEN r1 L HEALTH <br /> !; 22MIX EMIRA§ I YEAR PERM) 1 /SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby and to San Joaquin County for a permit to construct and/or install the stork herein described. This <br /> application is made in c:411ance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. - <br /> Job Address s4g r City Lot Size/Acreage <br /> -`"Owner's Name JOhnr l L Address `! Phone Z-1 <br /> Contractor rens ++ �f p�r License No. Phone_ <br /> Zi�� -iii.. x r v (0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C0DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION 0 SYSTEM REPAIR P OTHER Q Monitoring Well C� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f.] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> "omestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications ! <br /> M Public fel Other 0 Delta . Depth of Grout Seal Type of Grout y <br /> Ci Irrigation —..[Approx. Depth 0 Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done QU_Lud t % &,Q- C-1,�� <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JD REPAIRIADOITION 0 DESTRUCTION CI INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> t Number of fiving units: l Number of bedrooms <br /> Character o1 soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PI(G, TREATMENT PLT.❑ .` Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _._ __ Total length/size <br /> I <br /> FILTER BED n Distance to nearest:. Well Foundation Property`Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Disianoa 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'ia signature cenifies the followings "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 Cslllornia," 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," <br /> r <br /> The applica must call for r quired inspgctions. Complete drawing on rave a side. <br /> Signs � ��, _ Title: Date: <br /> -FCJA DEPARTMENT USE ONLY _ <br /> Application Accepted by <br /> II For <br /> /Date ( Area <br /> Pit or Grout Inspection by Date Final Inspection by f ata <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> l ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON. CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT AEMlTTEO CASH RECHVED BY DATE PERMIT'N0. <br /> r EH tS-2�IREY.i i n 5i S r-O'!� /� <br /> 4 �� <br />