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APPLICATION FOR PERMIT <br /> 'I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT MIRES 1 YEAR PROM DATE IS ,ED <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 coWliance 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 _9 54Yti e r St City Lot Size/Acreage ~k CJ <br /> Owner's Name ��� �(,� �6 V fA.Al Address .310 �ta-r nr Phone <br /> S <br /> ContractoriAddressm License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME C_l DESTRUCTION C1 Out of Service Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM R AIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER INES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL RE WE OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca a. f Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type Casing Specifications <br /> 3 Public -1 Other ❑ Delta Depth of rout Seal Type of Grout <br /> G Irboation �.Approx. Depth © Eastern Surface Se installed by <br /> Repair Work Done LJ Type of Pump H.P. ''`� State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material 8 De th <br /> Depth " Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO 0 REPAIR/ADDITION El DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.I ' <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line <br /> r <br /> 4 <br /> LEACHING LINE Cl No. & Length of lines Total length/sire k <br /> FILTER BED ❑ Distance to nearest: Well f=oundation Property Line 1 <br /> SEEPAGE PETS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby eenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and x <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." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." t <br /> KS <br /> The applicant must tail forall required inspections, Complete drawing on reverse side.igned X_i6 Lited ,.L(;• —'�'�^—.= Title: Date' <br /> �i FO EPARTMENT USE ONLY <br /> Application Accepted by _ .4etd ""� J„` Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: 1y_ t' 4a, r ✓ i <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 85201 <br /> i <br /> INFO AMOUNT DUE AMOUNT REMITTEp CASH RECEIVED BY DATE PERMIT NO. <br /> . EK{�,,. rnEv.,,»e. tt� L`f �. �z --1-i OX333 <br />