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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O Bog 2009, STOCKTON, CA 05201 <br /> (209) 468-3447 <br />- -YEAR . <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 cmwliance with San Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> f r <br /> Jab Address ... -00-1"-&K, <br /> rK, [fat,J A eCity Lot Site/Acreage <br /> Owner's Name ©'74t➢dress — - _ ----,--,—,• Phone ­J <br /> Contractor94;�ddresszz;�i <br /> &"!� Ljcense No. Phon642– <br /> .TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPL EMENT ❑ DESTRUCTION ❑ Out 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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia:of Well Excavation pis. of Well Casing <br /> U Domestic/Private 0 Grave! Pack ❑.Tracy Type of Casing Specifications <br /> D Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation _.Approx. Depth ❑ Eastern Surface Seri Installed by l <br /> Repair Work Done U Type of Pump H.P. State Work Done— <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE Of SEPTIC WORK: NEW'INSTALLATION O REPAIR/ADOITIOIT DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> Installation will save: Residence X Comrrierci Other <br /> Number of living unit s:� Number of bedroo 1 k <br /> Character of soil to a pdi th of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 'No. Componments ' <br /> PKG. TREATMENT PLT, CI <br /> Method of.Disposal <br /> �. Distance to nearest:' Well> - Foundation. Property Lina–442,2 <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Tota length/size <br /> FILTER BED Ll Distance to nearest: Well Foundation Property Line <br /> OrI <br /> SEEPAGE PITS 11 "Depth Size� f l_ _ _ . Number j <br /> SUMPS Li 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 Count? <br /> Hohte owner or licensed agent's signature certifies the following: "I certify•that in the performance of the worn for which this permit is issued, I shelf not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the perfofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laves of California." <br /> The a fired inspgc n mpiete drawing on reverse side. y <br /> Signed Title: Date: <br /> A <br /> FOR DEPARTMENT USE 6NLY <br /> A licatlan Accepted by e <br /> Dat ' ;ZDate <br /> r Grout Inspection by Date Finalinspection by �7j <br /> Additional Comments: <br /> Applicant – Return all copies to: SAN JOAQUIN COUNTY PUBLIC H ALTH SERVICES <br /> .2 ENVIRONMENTAL HEALTH DIVISION PERU IT/SERVICES .. <br /> 445 N AN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT'HEMITTED CASH RECEIVED BY DATE PERM17'NO. <br /> EH 13 24 1 REV. 51 � i "t� iraw (.. 6 EH,4.10 Z1,V <br />