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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9,5201 <br /> (209) 468-3447 i <br /> IR 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 made in comliance with San Joaquin County Ordinance No. '549 and 1862 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. a-.S x <br /> City Lot.Size/Acreage <br /> Job Address <br /> Owner's Name <br /> E DE t 12-o E L 1 Address Phone <br /> - <br /> F/_a <br /> Address - /�• ��— License No. ��'��•'�� -Phone ..'--� � <br /> WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Gl f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well C7 <br /> PUMP INSTALLATION CI SYSTEM REPAIR D <br /> DISPOSAL FLDPROP, LINE <br /> DISTANCE TO NEAREST:,SEPTIC TANK---�„••�,_.SEWER_LINES,. . PITS/SUMPS <br />�" FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial 11 Open Bottom LiManteca " � Dia. of Well Excavation — <br /> .` ! Specifications <br /> U Domestic/Private D Gravel Pack 0 Tracy *' Type of Casing <br /> Type of Grout <br /> L Public I;l Other ❑ Delta Depth of Grout Seal r <br /> 0 Iffigalion ._.Approx. Depth ❑ Eastern Surface Seal Instailed by <br /> .,.H-P, State Work Done _ <br /> Repair Work Dona--9--�VIS of-Pump--� Sealing Material i Depth <br /> Well Destruction © Well Diameter <br /> Piller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAfR/ADDITION M DESTRUCTION C; (No septiclable system <br /> m fmtitled if public Sewer is <br /> avaInstallation will serve, Residence — Com?r+erclal`=✓-ether "' l� .0Tr7ie <br /> Number of living units: Number of bedrooms �+ <br /> Character o1 soil to a depth of 3 feat: <br /> 1Wit"r able--Oth <br /> I SEPTIC TANK ❑ TypelMfg CC �g�L Capacity_f — No. Compartment] <br /> Method of Disposal <br /> PKG. TREATMENT PLT. 0 ''' <br /> Property Lina <br /> Distance to nearest: Well - :Foundarion _ <br /> " LEACHING LINE Cl No. 8 Length of lines Total length/348� <br /> FILTER BED nDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS It Depth Sire Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> Y DISPOSAL PONDS ❑ �-�� "� "'!� � - � ..: <br /> I hereby comity that I have prepared this application and that the work will be done ;n accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> s 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 /> Home owner or b <br /> employ any rpersontic in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sucontracting signature <br />� certifies the fol4owing: -I certify that in the performance of the work for which this permit is issued, k shall employ persons subject to workman's compensa <br /> J'•ilon taws of California." <br /> The`applicant must call for all required inspections. Complete drawing on reverse side. <br /> Si nsd Title: + Date: <br /> g FOR IEPATMENT USE ONLY <br /> Date Area <br /> Application Accepted by 9� <br /> Pit or Grout Inspection by <br /> "^"'aite:"""" '" MFinal Ins action Date <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 0 BOX 2009, STOCKTON. CA 65201 <br /> FEECK RECEIVED BY DATE PERMIT'N0. <br /> INFOav <br /> AMOUNT DUE AMOUNT <br /> MOLt. <br /> REMITTEq ��" <br /> ♦ fH 13•24 rrtEV.11451 l ( -+ . 6-0 LI-7 <br /> EH 14.26 <br />