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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM DATE ISSUED <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> x ! [a �Q- 1 <br /> / �J �KZg ':Y/U/� �i�� '"-:r City 7.ot Size/Acreage /7 C_• <br /> Job Address <br /> /11 <br /> Owner's Name (7 (J <br /> ��./i l r/C?�f 2 .!/Address /S Phone 7 <br /> f ' 1 !y <br /> �Q16- ',Address" /ZI t�.�/'511 �� - ie _C? Rlwn, ,ft i-3 <br /> U 1p PP. <br /> ObtPR3c10 <br /> TYPE OF WELL/RNEW WELL 13WELL REPLACEMENT ❑ DESTRUCTION L) -of Service Well " ❑ <br /> STALLATION ❑ SYSTEM REPAIR ❑ 07 Monl towing Well L) , n <br /> DISTANCE T I NEAREST: SEPTIC TAN SEWER LINES DISPOSAL F PROP. LINE <br /> FOUNDATION RICULTURE WELL OTNE WELL PITS/SUMPS _ <br /> r_ INTENDED USE TYPE OF WELL PROBLEM AREA NSTRU SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Di Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I7 Public I-1 Other 0 a Depth of Grout Seal _ Type of Grout <br /> 0 Inigation _Approx. O th "O Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type mp H.P. Stara Work Don <br /> Well Destruction ❑ all Diameter Sealing Material L Depth <br /> Depth Filler Material a Depth <br /> ,TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION Ll DESTRUCTION G (No septic system permitted it public sewer is <br /> available withirr200 feet.) <br /> Installation will serve: Residence Commercia Other <br /> Number of living units: ___L Number of bedrooms <br /> Character of soil to a depth/p1 3 feet: Water table depth <br /> SEPTIC TANK QY Type/Mfg 6 ( i2 P_ ',{' c:r,acity S� L No. Compartments + <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> /LEACHING LINE 5( No. g Length of lines Total length/size <br /> FILTER BED FT Distance to nearest: Well ��' Foundation Property Line <br /> i <br /> SEEPAGE PITS M Depth / Sire I X- Number <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 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 California." <br /> The applicant must call for ail r fired inspection . omplete drawing on reverse side. <br /> Signed x/..�{%/��`/r ��/ Title: L' <br /> fA� F DEPARTMENT USE ONLY <br /> r. Application Accepted by Date Cres <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> s <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 O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, <br /> EM 13-24 � ,�-i . � , CC) m ssi <br /> .1 <br /> •EH 1 -26 <br />