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w <br /> 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 E%PIRBS I YEAR FROM DATE <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 ceWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. [/ <br /> Job Address -71 � V �/�. „„ City ' Lot Slte/Acreage < <br /> Owner's Name _`-� /�-�OL A Address �-'�' ` �C Phone { �� <br /> Contractor Address ^c ` dy- 3 <br /> - _ ._ License No. 5Z�7! Phone 7a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION jF9t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ <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 /> 0 Industrial U Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O Gravel Peck ❑ Tracy Type of Casing_ Specifications <br /> f'3 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation .,,._Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction 1�1 Well Diameter Sealing Material i Depth C, cf' <br /> J _ Depth /OD 4 Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is )1s,available within 200 feet.l <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. A Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 /> The applicant must c4for all equir inspections. Complete drawing on reverse side. c, <br /> Signed X. Title: ly ! Z <br /> Date: <br /> OR D ARTMENT USE ONLY <br /> I <br /> Application Accepted by Data Area Z' <br /> Pit or Grout Inspection by Date Final Inspect' by Date44 <br /> Additional Comments: ftze� 4 i <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 /> INFO FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> �3 J <br /> a EH14-24IAEV.F/nSY �� <br /> �Ctv <br /> EH t4-]e ���/// V ' <br />