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APPLICATION FOR PERMIT " <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION j <br /> P O BOX 2009, STOCKTON, CA 95201- <br /> (209) <br /> 5201(209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR-_PUN DATE 12SUSD <br /> (Complete in Triplicate) <br /> Application to hereby made,to San Joaquin County for a permit to construct end/or install the work herein described. This <br /> application In made 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 /> I � II <br /> Job Addros City Lot Size/Acreage _75X <br /> Owner's Name .., � Address �a�M� _ . Phon <br /> F'yT�'o <br /> Conlraclor Addressv�f� • v _ —Lise No ho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CI DESTRUCTION ❑ Out of Service well ❑- _. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 41elIT Lj <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 Q <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications <br /> M PLFblic i l Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M tro0ation Approx. Depth ❑ 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 i Depth <br /> Depth Piller Material i Depth may" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIRIADDITIO DESTRUCTION Irl (No septic system permitted if public sewer is <br /> t . available within 200 feet.l <br /> Installation will serve: Residence_ Commercial T Other _ <br /> Number of living units: _ _ Number of bedrooms A?- t <br /> Character of soil to i depth of 3 feet: Water table depth. --� <br /> SEPTIC TANK. $. Type/Mf Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ OfMethod of Disposal <br /> Distance to nearest: Well hIAMN Foundation Property Line <br /> LEACHING LINE No. & Length of lines Q� Total Iendth/size <br /> FILTER BED [0 tante to nearest: Well"1&2H�Fouhdstion`� Property Line �d <br /> ,,..•,� . . .rte <br /> SEEPAGE PITS Depth 2 S Size Number <br /> SUMPS is Distance to nearest: Well ont,0— Foundation h!!2 Property Line = _ <br /> DISPOSAL PONDS ❑ <br /> I hereby sonify 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 x <br /> Home owner or licensed agent's signature certifies the following; "I certify that iii.ihe 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 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 /> i The applicant must call-f uired inspections. omplete drawing on reverse side. <br /> Signed <br /> o. . Date: <br /> Title: <br /> R DEPARTMENT USE ONLY <br /> i <br /> I Application Accepted by i � tl`�' Data R D`� Area <br /> 4 Pit or Grout Inspection by Date- <br /> Final inspection by DateQ <br /> s <br /> Additional Comments <br /> Applicant - Raturn 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 SCA--95201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> "rEM t,. (REV. /n5i 1 LqI 1d 3a-9-0 �b-Am _4l <br />