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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION + <br /> P O BOX 2009, STOCKTON, CA 95203 m"s <br /> (209) 468-3447 MAR <br /> PERMIT EXPIRES 1 YEAR rjg X DATE ISSU$FNVIRON' �: } <br /> (Complete in Triplicate) PERPN,;4 <br /> 3 <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 CoWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules amd Regulations of Ban <br /> Joaquin County Public Health Services. <br /> � 4 <br /> Job Address I- ��rr3 T5� City Lot Size/Acreage <br /> Owner's Name JQ&U '— 7adj—Address - - ___ Phone <br /> Contractor _Address -S ® License No. 2 6 2r Phone <br /> TYPE OF WELLIPUMP: NEW WELL ID WELL REPLACEMENT DC7 DESTRUCTION ❑ Out of Service Well <br /> r� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well G� <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 /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> PIPomestic/Private O Gravel Pack n Tracy Type of Casing Specifications <br /> D Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation .Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done Type of Pump - H.P. State Work Done c <br /> Well Destruction ❑ Welt Diameter Sealing Material i Depth _ 1L- <br /> Depth hiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION CJ 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 of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity-- No. Compartments <br /> PKG. TREATMENT PLT,Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No. 8 Length of tines Total length/size <br /> FILTER BED I.1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 Californla." <br /> The applicant mu or all required inspections, Complete drawing on reverse side. <br /> r j <br /> Signed X Title: A.JW. <br /> F R WARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date�/1 <br /> Additional Comments: _ <br /> Applicant - Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> INFO <br /> EEE AMOUNT DUE AMOUNT REMITTED CASH R�ECCEIVEE0 BY DATE PERMI-r'NO. <br /> . EH 13.24 TREY.I/n 51 •r 1 l 1 A J �� �1 Q�-„(d[°7� <br />