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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> gEgIJIT BUIRES 1 YEAR 980H 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 /> � City Lot Size/Acreage <br /> Job Address <br /> Owner's Name Q_&LA"1k`._..� Address Phone <br /> 4c `3QLicense � <br /> ContractddrePhon <br /> . <br /> TYPE OF WELL/PUMP: NEW WELL C3WELL REPLACEMENT 0 DE TRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0,--' OTHER C3Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ClIndu k ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omaatic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public (.1 Other a Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation Approx. Depth 0 Eastern Surface Soul Installed by <br /> Repair Work Done I`Y Type of Pump H,P. �� State Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Materia] i Depth r <br /> Depth Filler Material i Depth fVVV��,I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial ___ Other <br /> Number of living units: Number of bedrooms oaf <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity_, _ No. Compartments <br /> PKG. TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED (-i Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS ( I Depth Sue 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 comity that in the performance of the work for which this pirmit is issued. I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus farIIIIII requirepsctions. Complete drawing on verse.side. <br /> Signed Title: i Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date f �'Z Area <br /> Pit or Grout Inspection by Date Final Inspection by Data_*ZJZ- <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 AMOUNT DUE AMOUNT rtEMITTED CK # I RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH 13•24IIIEY.1/"51 <br /> EH i42a <br />