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r <br /> APPLICATION FOR PERI[I Ts . <br /> yl SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIONN.0 V3 _ <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 s-k: XA& ,o\� <br /> �! <br /> PERMIT EXPIRES- 1 YEAR FROM DATE ISSUM <br /> !!!1 (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. /fr� r� <br /> t Job Address '! r` r City C Yet Size/Acreage C� <br /> t <br /> Name <br /> Owner's V Ir,54dress f,y• �l�/J �1�P� Phone <br /> � X y: . <br /> Contractor _ _Address License No. Phone <br /> of Service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out Monitoring Well C1PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O <br /> k _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS L9 <br /> k <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I 0 Industrial ❑ open Bottom ❑ Manteca Dia- of Welt Excavation Dia. of Well Casing <br /> (-,I DomeatiC/PFIVate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'I Public n Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done Q Type of Pump H.P. State Work Done _ <br /> f Well Destruction ❑ Well diameter Sealing Material a Depth Z <br /> t Depth Filler Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCT4GN41iNo septic system permitted it public sewer is <br /> M vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: -4 Number of bedroo s r <br /> Character of soll to a depth of 3 feet: - - Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg G Capacity—19 No. Compartments <br /> �' "`MatF d of Disposal <br /> f PKC. TREATMENT PLT.❑ iiE <br /> Distance to nearest: Well Foundation Property Line rr <br /> l 1. <br /> 170, <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> t it <br /> SEEPAGE PITS it Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation _Property Line <br /> DISPOSAL PONDS ❑ iI <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, end <br /> t rulas 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 mahnsr as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 afl'requir I inspection*. Complete drawing on reverse side. <br /> I !Signed Title: 1 Date: <br /> 2 FOR PARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout lnspectio II Date inal_Ins ctign by Date <br /> � � 1 <br /> Additional Comments: <br /> I <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 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> G INFO <br /> ,i: 19-3_ o o <br /> . CH 1344(A riebl S t� L7 �.O`7 1~ <br /> Ex t�•Ia <br /> " ff _ <br />