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APPLICATION FOR PERIL 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 <br /> Y <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 coatipllanoe with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servicers <br /> Job Address P3- <br /> " ,1 City Lot Site/Acreage <br /> Owner's Name �/ /U��Of Address (�4p <br /> Phone <br /> • Contractor i9A14--� Address <br /> License No, Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTIONANkut of Service—We-11 C) <br /> PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK L7 <br /> SEWER LINES � DISPOSAL PLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL + OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT10.'k ECIFICAT10NS <br /> n Industria, ❑ Open Bottom ❑ Manteca is. of Well Excavation ' <br /> LJ Domestic/Privatew Dia. of Weil Casing <br /> Cl Gravel Pack ..❑ Tracy Type of Casing ''�'•: <br /> M Public f") Other ❑ Delta Specifications <br /> Depth of Grout Seal. Type of Grout <br /> GI irrigation —Approx. Depth Cl Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump H.P. n <br /> State Work Done <br /> Well Destruction ❑ Welf Diameter f Sealing Material i Depth _ i <br /> Depth _ C 73�S v `Filler"iiaterial i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION M, DESTRUCTION Cl (No septic system permuted if public sewer is <br /> Installation will serve: Residence *Commercial_ ~ available within 200 feet.l (, <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK. ❑ Type/Mfg Water table depth ; <br /> PKG. TREATMENT PLT. 0 Capacity • - No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation. , <br /> Property Lina <br /> LEACHING LINE Ll No. & Length of lines I <br /> FILTER BED <br /> [I Distance to nearest: Total length/size <br /> Well Foundation _ I <br /> Property Line <br /> SEEPAGE PITS 11 Depth Size _ <br /> SUMPS = Number <br /> LI Distance to nearest: Wall Foundation <br /> DISPOSAL PONDS p ------ Property Line <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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I canify 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 sub-contracting signature <br /> certifies the following: "l Certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa• <br /> tion laws of California." ' <br /> The applica ust call for all required ins tions. Complete drawing on reverse side. <br /> Signed !� <br /> Title: ��9 <br /> Date:f/ <br /> OR DEPARTMENT VSE ONLY <br /> Application Accepted by <br /> Date '� Area <br /> Pit or Grout Inspection by Date _ Finaf q <br /> En:pection b Dats� �6 C <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, STE)CKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INF A5 RECEIVED 8Y DATE PERMI7"N0. <br /> . EH14-24IPEV.iir9� <br /> EM;{-2e <br />