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r <br /> APPLICATi N FOR PERMIT <br /> SAN .TOA UZN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009 STOCKTON CA 95201 <br /> (209) 468-3447 <br /> V..- PENIT .RSPIRES 1 MBAR PROM DATE 15SULD <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County.for a permit to construct acrd/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> In <br /> Job Address City�rs Lot Size/7l-ciagei2yte <br /> Owner's Name A!20 Z_ tom„f Z& ea Address : ys & 14Phone <br /> Contracto6 <br /> cr Address eke License N' Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION 0 Out of Service Well LlPUMP INSTALLATION 0 LSYSTEM REPAIR ;[ OTHER ❑ Monitoring Well C3 <br /> kkk 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 /> 11 Industrial ❑ Open Bottom ❑ Manteca - Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public fl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> �Cfr6jjarion� 4.i e6 Approx. Depth Eastern Surface Seal Installed by <br /> Repair Work Done Id' Type of Pump H.P. State Work Don <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material fy Depth' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION El lNo septic system permitted if public sewer is <br /> available within 200 foist.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units; Number of bedrooms <br /> i Character of soil to a depth of 3 foot: _ Water table depth <br /> SEPTIC TANK O Type/MfgCapacity g No. Compartments <br /> L <br /> PKG. TREATMENT PLT..❑ f Method of Disposal <br /> Distance to nearest: Well Foundation PropertyLine <br /> LEACHING LINE 0 No. & Length of tines Total length/size <br /> s r FILTER BED [1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Lt .Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 /> j Home owner or licensed agent's signature cartifies 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 subcontracting siqpalure <br /> certifies the following: "I certify that in the performance of the work for which this pormit is issued, I shall employ persons subject t/workm 'sco pensa- <br /> tlon laws of7rmnucall <br /> ,, <br /> Th paicanfor all re ins ions. Complete drawing o verse side. <br /> + Signed Title: Date: <br /> DEPARTMENT USE ONLY ; <br /> Application Accepted by Date �� Area <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 DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX.2008i STOCKTON, CA 85201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CK GASH RECEIVED By DATE PERMIT NO. <br /> Ell 17.21 011y.r/n as <br />