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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 MIRES I YEAR FRQM-- DATE ISSREP <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 trade in compliance With Sao Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ry <br /> Job Address `- City Lot Size/Acreage SC?X ib 0 <br /> t <br /> Owner's Name __ a Address Phone <br /> Contractor Vv ■� Addresse No. 3°fione <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION"L Out of Service Yell 0- <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O <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 /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> F1 Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____Approx. Depth l 1 Eastern_ _Surface Seal installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONA I REPAIR/ADDITION I RUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: R Wence commercial— Other <br /> Number of living units: Number of ms <br /> Character of soil to a depth of 3 feet: f} Water table depth <br /> SEPTIC TANK. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r Method of Disposal (' <br /> Distance to nearest:, 11 Foundat' n Z Property Line <br /> LL2!Q / � <br /> LEACHING LINE L9rWo_. b Length of lines � Tota�.length/size <br /> FILTER BED ❑ Distance to nearest: W Founds ion Property Line­1 1 <br /> SEEPAGE PITS I I Depth Size "�`- ber <br /> SUMPS Istance to rrsa 1Alell 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 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 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 taws of California." <br /> aP s call or do s. Complet drawing on r side, <br /> Sig Title: Date: ZZr <br /> R DEPARTMENT USE ONLY t <br /> Application Accepted by Date I HLL Area SLf-2- 1 <br /> Pit or Grout Inspection by Data final Inspection h <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 /> IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY , ATE /PERMIT'NO. <br /> + EK tY24(M.fieSl190 <br /> / <br /> EM tl-m (7� / `� <br />