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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby reads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance Frith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �c Job Address r City 7 � A Lot Size/Acreage <br /> Owner's Name S S I,tk-eddess _� 5 �"" --- Phone <br /> _ Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well 0 <br /> 4— �``- Monitoring Well <br /> PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ <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 /> !_� Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy rr Type of Casing Specifications <br /> ID Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation _Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material i Depth <br /> Depthciterieal i Depth <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RE lR" I EST 51 . slam permitted if public sewer is <br /> leit in 200 feet.i <br /> Installation will serve: Residence— Commercial_ 0 {� <br /> Number of living units: Number of bedrooms ._ I fit May '+ ter eyPjr d W1 <br /> Character of soil to a depth of 3 feet: _ �A.ter table depth <br /> t! f_-se, a aei lngog <br /> SEPTIC TANK ❑ Type/Mfg p�. �ytdCompartmenta <br /> PKG. TREATMENT PLT. Cl I" - } �il � ihod of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> e4. <br /> LEACHING UNE ❑ No. & Length of lines Total lengthtsize <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O t <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 6 to become subject to wdrkmah's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies thefoil wing: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> I _. ,lion laws of Csli <br /> The appsn mu II for all ^equir in ilns. rete drawing on reverse side. <br /> XSigned Title:- d ate: /2—A30-22 <br /> Ocm4 <br /> OR-DEPARTMENT' USE ONLY,Acca ted b Date Area <br /> f <br /> Application ' y <br /> I Pit or Grout Inspection by Date Final Inspection by Date <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 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH if <br /> EH 13-24 IRIV.1/N51 At�� <br /> EH 74.26 <br /> i <br />