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APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI(REC <br /> ENVIRONMENTAL HEALTH DIVISION G, <br /> P 0 BOX 2009, STOCKTON, CA 95201 J U N 13 1991 <br /> (209) 468-3.447 <br /> PZRM. ITURT ENVIRONMENTAL HEA`..11°l <br /> $��YEAR I�ROId DATE iSS <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 /> Job Address aa„_ City Lot Size/Acreage <br /> d <br /> Owner's Name � Address Phone <br /> Contract Address �` <br /> 1�r -�� 2i3_4 License N Rhone + f <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT C1 DESTRUCTION 0 Out of Service well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR 31—' OTHER ❑ Monitoring well L� <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 /> n Ind iiol C3Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> omestic/Private 0 Gravel Pack C1 Tracy Type of Casing Specifications <br /> L Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout �} <br /> M Irrigation /`'� Approx, Depth ❑ Eastern I Surface Sad! Installed by <br /> Repair Work Done l Type of Pump ea -+ — H.P. lfl= State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wilt 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 f <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT. 0 Method of Disposal LA <br /> Distance to nearest: Well Foundation Property Line <br /> a <br /> r_ LEACHING LINE 0 No. & Length of lines a Total length/size , <br /> FILTER BED E_] Distance to nearest: Well Foundation Property Line ; <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS p _ - <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, t shall not <br /> 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, I shall employ persons subject to workman's compensa• <br /> tion laws of California." <br /> The applicant must-50 for all required insp(,ctions. Complete drawing on averse side. <br /> Signed X Title: Date: <br /> r � <br /> ` FOR O PARTMENT USE ONLY <br /> Application Accepted by Data / Area <br /> Pit or Grout Inspection by Date Final Inspection by ata <br /> Additional Comments: <br /> Applicant - Return all copies to., SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO <br /> FEE, AMOUNT DUE AMOUNT REMITTED CASH RECyE/IIVEEDBY ` DATE PERMIT'NO. <br /> • EH 13-36 IM.i/"SP <br /> EH 114-116�114-116f�{{U _ 111-4LITY <br /> K � t y AV <br />