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K <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYj Z <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOC.KTON, CA 95201 �� � '�� <br /> (209) 468-3447 N0V 03 1992 <br /> S.IN JOAQUIN <br /> Y R , COUNTY <br /> UbLIC HEALTH SE:RvICES <br /> (Complete in Triplicate) ENVfF?0NA1E p � <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork hereiFn�d'lk crit;4d,t�,Thie <br /> application is made in co�lisace with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se vices. <br /> Job Address Cit Lot Size/Acreage <br /> Owner's Name Address K' Phone <br /> Contras Addre � .. License ��raZ Phonal <br /> TYPE OF WELL/PUMP: NEW WELL � WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION E]--� SYSTEM REPAIR 93-' OTHER El Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial D Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing <br /> omestie/Private ,❑ Gravel Pack M 0 Tracy Type of Casing Specifications l <br /> M Public Ill Other 0 Delta Depth of Grout Seal Type of Grout N <br /> Cl Irrigation - Approx, Depth 0 Eastern Surface Soul Installed by (� <br /> Repair Work Dona F� Type of Pump. H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION G 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 o1 soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments w <br /> PKG. TREATMENT PLT. D _ Method of Disposal W { <br /> Distance to nearest: Well Foundation Property Line <br /> x , <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED D Distance to nearest: Well '� Foundation ?Property Line <br /> SEEPAGE PITS I ]` Depth l-``- Size Number - I <br /> SUMPS LI Distancs-10 nearest:_ Well Foundation Property Line <br /> DISPOSAL PONDS D �- -_ �•- ` <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 '� 'i'^ _ - - •- . <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this peimiris issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> eanifiea the following: "I sonify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa� <br /> F tion laws of California." <br /> The applican st ca, all required ins ctions. Complete drawing on arse side. <br /> Signed x Title: I Date: �n= <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date w <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 2009, STOCKTON. CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO �y <br /> EH 13.24 II�EV,,rKS, f� `T-� f7ZJ �� d� 1.3Z&o CMCJ it T1� �"`3rD� <br /> EH 71•� r <br />