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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S&RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> 1 'I <br /> PERMIT EXPIRES 1 YEAR FROM DATE- ISSUM <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r GD City RlpLot size/Acreage <br /> Jab Address <br /> N <br /> Phone <br /> Slr+7P50/�! PQPSR Address ^Ot <br /> Owner's Name <br /> 1, 4' <br /> Contractor L � L Alt/ E �'A <br /> Address /x-q�'� � JP MOA. License No. Phone <br /> TYPE OF WELL/pump:P: NEW WELL ❑ WELL REPLACEMENT 1 i DESTRUCTION Cl t of Service Well ❑ <br /> Monitoring we ❑ <br /> h PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER SAIL BORInlC�S �e4) <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE AX 151 vaep <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSfw E <br /> " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I ) Irrigation —Approx. Depth I I Eastern Surface Seed Installed by <br /> Repair Work Done 0 Type of Pump H.P. Stats Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth biller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> „Character of sag to■depth of$feet: Water table depth r <br /> SEPTIC TANK. 0 TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT.PLT.0 Method of Disposal <br /> �I Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE Cl No, b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Weil Foundation Property Line <br /> SEEPAGE PITS It Depth Sue Number' <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, an <br /> 03 <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 /> M 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,1 shall employ persons subject to workman's compensa- <br /> 1 <br /> I tion laws of Cali is." <br /> The applica at call for red inspections. Complete drawing on reverse side. <br /> I <br /> Sigma Title: U C€ Date: <br /> N FOR DEPARTMENT USE ONLY �7n <br /> Application Accepted by <br /> Date/B aa h <br /> Date�� <br /> Pit or Grout Inspection ib Date FIns coot►b <br /> Additional Comments: •� � 'a i <br /> Applicant - Return all copies to: San Joaq in County public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95207 <br /> FEE AMOUNT DUE AMOUNT REMITTED %CT-S-H RECEIVED BY DATE PERMIT'NU, <br /> INFO <br /> c <br /> . Err 13-24lItEV.1/+15 p v / " 571 4^� � <br /> EM 14.2) <br />