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y APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Py <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y R <br /> (Complete in Triplicate). <br /> Application in hereby made to San Joaquin County for a permit to construct and/or' install the 6ork herein described. This <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 an <br /> Joaquin County Public Health Services. d 1862 and the Rules and Regulations of San <br /> Job Address .= 1= '" City Lot Size/Acreage <br /> Owner's Name DhAl, Address A Phone ZV(5 6,3 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well G7 t <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ' OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSC <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' + <br /> 11 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing4 <br /> Specifications <br /> M Public (I Other ❑ Delta Depth of Grout Seal Type of Grout <br /> U irrigation Ap}uox, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. Stale Work Done <br /> Well Destruction 0 Well Diameter .Sealing Material & Depth <br /> Depth Filler Material Ir Depth <br /> TYPE.OF SEPTIC WORK: . NEW INSTALLATION REPA 1ADQITION M x DESTRUCTION (No septics stem <br /> r Y permitted it public sewer is <br /> S e7wr-t _ f+{{ye, 1 Il f available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> c <br /> Number of living units: O Number of bedrooms © 11 <br /> fvo <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. M Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesi <br /> Total length/sire L <br /> FILTER BED D Distance-to nearest: Well Foundation Property Line <br /> ���OOO <br /> SEEPAGE PITS 11 Depth Sizet <br /> Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 <br /> tion laws oL'ornW." p p y persons subject to workman's compensa-The appiicaall fora 1 required . spgctions. Complete drawing ren reverse side. i <br /> Signed <br /> Title Date: <br /> SL'MIRIIEPARTMENT USE ONLY - <br /> Applicstion Accepted by Date€ d Area <br /> Pit or Grout Inspection by Date f=inal Inspection by <br /> Date J� 1 <br /> "itional Comments: <br /> Applicant • Retum.S11 copies to: SAH JOAQUIN COUNTY PUBLIC HHALTIJ SERVICES V, i <br /> a <br /> FEE <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN; P O BOX 2009, STOCKTOn, CA 88201 <br /> AMOUNT DUE AMOUNT REMrT7ED <br /> ,NFO CASH RECEiVEO BY { DATE PEAM17'N0. <br /> i13•21rREV.rieSr I, <br /> 7 ;f•se <br /> �1 <br />