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lL ` <br /> APPLI CATI ON FOR PERF I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ,�- - — P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 r ` <br /> PMWIT MIRESLI YEARPM-DATE I•SSUSD <br /> (Complete in Triplicate) <br /> Application is hereby uiade.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. I <br /> Job Address 0� rYr r City- Lot Sime/Acreage <br /> • /} 1 <br /> Owner's Name Addressy Phone <br /> Contractor Address <br /> License N PhoneL. <br /> TYPE OF WELL/PUMP: N W WELL WELL REPLACEMENT 0 DESTRUCTION Kout of Service well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER O <br /> Monitoring Well O I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT �S� <br /> CIindustrial Open Bottom D Manteca Die, of Well ExcavatioDia. of Well Getting <br /> Oomestic/Private 0 Gravel Pack. E3 Tracy Type of Casing ? ® specifications <br /> 0 Public fa Other ❑ Delta Depth of Grout Seal + yp Grout <br /> Irrigation <br /> Appro><. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done 0 Type of Pump Depth C1 <br /> --- H.P. State Work Done <br /> Welt Destruction O Well Diameter sealing Materials i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION n REPAIR/ADDITION M DESTRUCTION CI (No 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 µ <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 7 Foundation Property Line <br /> ` LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: ;Wall 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'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 comity 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 appficant u call for alllrr qur?a inspections. Complete drawing on reverse side. <br /> Signed x �*�.! �4 - - Title: iu Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by r - Data Z at �� Area <br /> PitGrout ins coon by Date Final Inspection by L^'w Date <br /> ( l f a 43, 4yt t S{l�f hots ^� <br /> + Additional Comments: eIr <br /> 1 <br /> Applicant - Return e11 Copies t SAN JO QUIN COUNTY PUBLIC HEALTH SHRVICES Gra sufd !i u - <br /> rvt? CLS <br /> ppf o� Se.0 CG <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 G-Af1/ <br /> PEE AMOUNT DUE AMOUNT REMITTEDSASH RECEIVED BY DATE lt// P••ERMIT NO. lel <br /> INFO <br /> o <br /> EH <br /> tN 13-21 rpEY. <br /> h <br />