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APPLICATION FOR PERMIT <br /> SAN ..rJAQUIN COUNTY PUBLIC HEALTH a�RVICES <br /> ENVIRONMENTAL HF.AT•TH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in 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 /> kJob Address �L7� I�1 �JL!T Cit 't Lot Size/Acreage G� <br /> Owner's Name�`� Q j�_1 c L'a Y1 Address ��t'�S ������ Phone �T� <br /> Contractor �� f1Q (ZR-1 G d t-- Address ? yi�C License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL I WELL REPLAC ENT ( DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTE REPAIR ❑ OTHER C1 r" <br /> Well C]DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICULTURE ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A EA 0NSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom G Manteca Die. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private ❑ Gravel Peck ❑ Tracy / Type of Casing_ Specifications <br /> ('1 Public Cl Other n Delta J th of Grout Seal Type of Grout <br /> I I IrriUation _Approx. Depth I I Eastern Surf a Soul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well DiameterSealing Materi i Depth <br /> Depth Filler Material A Depth <br /> /_­1YPE OF SEPTIC WORK: NEW INSTALLATION I I' REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feel) f1 n <br /> Installation will serve: Residence _ Commercial & Other �IF V <br /> Number of living units: Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments \ <br /> 1 PKG. TREATMENT PLT. ❑ Method of Disposal <br /> / 1 <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE A[ No. 6 Length of lines / — <br /> Total length/sizeeft) l� <br /> FILTER BED O Distance to nearest: Wellf <br /> Foundation 1,(7- Property Line <br /> SEEPAGE PITS A' Depth Z� tt <br /> SUMPS U Size Number Distance to nearest: Well S Foundation Property Line <br /> 1 a Lr i J <br /> DISPOSAL PONDS ❑ /��`? 7 <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, an <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 subtect 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,isaued, I shall employ persons subject to workman's compenss. <br /> tion laws of California." <br /> The applicant must catLfor rsAuired inspections. Complete drawing on reverse side. <br /> / Sip Title: ` tal T <br /> _ Date: <br /> i <br /> ((\\���� OR DEPARTMENT USE ONLY �Cc <br /> Application Accepted by t�JLVCz_%- —C\ �y p 9",sem DateI ' <br /> 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 Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO f� CAS <br /> H 17-21(REV <br /> M �.2a t/� <br /> 11� <br />