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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOg 2009, STOCKTON, CA 95201 <br /> PERMIT E%PIRFQ 1 YEAR FROM DATE I S <br /> uFn <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 co�llance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 2D Cit <br /> "7 VLot Size/Acreage <br /> Owner's Name W7- Address <br /> PPO Phone <br /> Contractor _Address_ �U• // n <br /> TYPE OF WELL/PUMP: ��r—tt_ License No � f�Phone <br /> NEW WELL O WELL REPLACEMENT Cl <br /> DESTRUCTION ❑ Out of service i1e11 O <br /> PUMP INSTALLATION O SYSTEM REPAIR O <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER O Monitoring Well U <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E] Industrial O Open Bottom (5 Manteca <br /> Dia. of Well Excavation Dia. of Wall Casing <br /> C I Domestic/Private D Gravel Pack O Tracy T <br /> I'I Public Type of Casing_ Specifications <br /> Cl Other n Delta Depth of Grout Seal <br /> I I Irrigation Approx. Depth I I Eastern Type of Grout <br /> _ <br /> Repair Work Done U T Surface Seal Installed by <br /> Type of Pump N.P. <br /> Well Destruction O Well Diameter Sealing Material Depth State Work Done _ <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial-)Z- Other available within 200 feet.) <br /> 1 b.f S <br /> Number of Irving units: Number of bedrooms <br /> Character of 900 to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg �� Water table depth <br /> PKG. TREATMENT PLT. O CapacityIz -- No. Com <br /> partmenU <br /> Distance to nearest: Well Method of Disposal <br /> Foundation _lam Property Line <br /> LEACHING LINE O No. & Length of linea <br /> FILTER BED O Distance to nearest: WelltFr Total length/size <br /> — Foundation _ Property Line __6L /—T- <br /> SEEPAGE PITS 11 Depth <br /> Size <br /> SUMPS LI Distance to nearest: Well Number <br /> DISPOSAL PONDS O Foundation 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 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 /> tioncertifies the foNowing: "I certify that in the performance of the work for which this permit is issued, I shall em to <br /> tion laws of Colilornla p y persons subject to workman's compensa- <br /> mpanu- <br /> pplicant must call for requ'rad inspections. Complete drawing on r arse <br /> Signed X �� Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A Z <br /> �\ Date - / Z Area <br /> P r G�put Insp�tio by 3 �6 / f <br /> .f� I Date — Final Inspection by <br /> Additional Comments:j Data <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED K <br /> CASH RECEIVED BY DATE <br /> PERMIT NO. <br /> --- <br /> 1-24(REV.1/ 51 �f V-D t O <br /> 2s ../��J V �/� 0s1 <br />