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z:Q� P" <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION {vole <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y R <br /> (Complete in Triplicate) moll <br /> Application is hereby made to San Joaquin County for a permit to construct end/or install the work herein descYibed. This <br /> application is made in ccupliance with 4an Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public?? Health Services. �� <br /> L� JY)(� / r'� City Ly <br /> Job Address Lot Size;. /Acreage <br /> Address Phone <br /> Owner's Name p `"' <br /> V` r &I� (-.Address af <br /> icense foo hone <br /> Contractorvice Well*0of Servic <br /> TYPE OF WELL/PUMP'. NEW WELL ❑ WELL REPLACEM T C_ DESTRUCTION ❑ Out Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS . <br /> ! Dia. of We1I Casing <br /> n <br /> n Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavatio , <br /> Specifications <br /> ❑ Tacy Type of Casing <br /> CJ Domestic/Private ❑.Gravel Pack - <br /> Typa'of Grout ' <br /> M Public i:1 Other El Delia Depth of Grout Seal <br /> Gl Irrioation ___�..Approrr:-Depth Cl Eastern- -----Surf ace Soul Installed by <br /> H.P. State Work Dona <br /> Repair Work Dona U .Type of Pump sealing Material i Depth <br /> E � l.J <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br />�4 TYPE OF SEPTIC'WORK: NEW INSTALLATION Ll REPAIR/ADOITION 0 DESTRUCTION8fvailableo septic systemithin rented if public sewer is <br /> I Installation will serve: Residence — Commercial Othery <br /> Number of living units: Number of bedroomsWa'Water table d�� <br /> Character of soil to a depth of 3 feet: <br /> L]P L depth <br /> h <br /> No. Compartments <br /> I' SEPTIC TANK. ❑ Type/Mfg Capacity w• <br /> r Ll Method of Disposal <br /> PKG. TREATMENT PLT. . <br /> l Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ® No. 8 Length of lines yTotal length/airs <br /> FILTER BED 1=7 Distance to nearest: lwell Foundation �Propeny Lina <br /> SEEPAGE PITS I I Depth - Size Number <br /> r <br /> SUMPS L! 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 San Joaquin County <br /> Home owner or licensed agent;: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 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 compensq- <br /> lion taws of California." <br /> The applicant must call for all required c ' AComplteg on reverse side. Date: I�ARTMENT USE ONLY <br /> i n Accepted bA F Dal e ��3��5�' Area <br /> A}}iicat e } Y <br /> Pit or Grout Inspection by <br /> Date Final Inspection by -- Datil U 1 d <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 2008, STOCKTON. CA 85201 <br /> FEE <br /> INFO OUNT DUE AMOUNT REMITTED CKX CASH RECEIVED BY DATE[ PERMIT N0. � <br /> r EH 13.24 01EV.r/n 51 <br /> EH A-26 <br />