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G <br /> ° APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM T E%P I RES 1 YEAR FROM{' D TE ISSUED <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.xith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Seerrv7iic�eQs_ <br /> t/�Job Address ��2 � �/'�"� � City _Jr_' Lot Size/Acreage <br /> /� <br /> 0(Owner's Name- 01 Address < 9-_:-� 417 "A/__/ <br /> _-_- Phone 7 �9 W;1 <br /> Contractor f rasa ! l _z_ "� ;/ 4' C�License No. Phone <br /> _Phone 7 J27� <br /> 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION t of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ] <br /> 0 Industrial ❑ Open Bottom " ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i r <br /> Cl Domestic/Private ❑ Gravel Pack..{ '.10 Tracy Type of Casing_ Specifications <br /> I'l Public 11 Other alt fl Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation ___..Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pumt'+ H.P. State Work Done �` <br /> Wall Destruction Ix Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I l DESTRUCTION I 1 lNo septic system permitted if public sewer is - <br /> available within 200 teat.! <br /> Installation will serve: Residence—i Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soN to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ i � � Method of Disposal +� <br /> Distance to nearest: Well Foundation Property Line L <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth ! Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation - Property Line <br /> DISPOSAL PONDS ❑ C <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'.a'signature.certifies the following_ "I certify that in the performance of the work for which this permit is issued, I shall not <br /> empty any person in such manner as to b;ec. - -subject to workmsri'scompansation,taws 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." x _ <br /> The applicant st cal for r uir nspec ions. Complete drawing on reverse,side. <br /> t I. t <br /> Signed Title: ---�''��-�" - --�-" � _ Data: <br /> OR DEPARTMENT USE ONLY t <br /> Application Accepted by Date Area �2— 1 <br /> 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 Permit/Services <br /> 1 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CX V CASH_ RECEIVED BY DATE PERMIT'NO. <br /> . EH14-211REV.tinsi ( d *d� l .f7 <br />