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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 /> IPERMIT EMPIRES 1 YEAR. PROM PATE ISSUM <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 conpliance.with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I � • <br /> Job Address City Jit -' ot Size/Acreage <br /> Owner's Name <br /> �t�+nr..`C� [ � ddress Phone <br /> Contract � � ddressf Yjcense'No -'78-2_—Phones <br /> TYPE OF WELLIPUMP. NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ElSYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO: PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Indus .let C3 Open Bottom © Manteca Dia. of Well E>tcavation Dia. of Well Casing <br /> omestic/Private C1 Gravel Pack 0 Tracy Type'of Casing Specifications <br /> 0 Public is Other O Delta Depth of Grout Seal Type of Grout <br /> G Irrigation '"Approx."Depth C) Eastern Surface Seal Installed by o(� <br /> Repair Work Done 4­ Type of Pump / H.P. '"'-` State Work Done �,e <br /> Will Destruction O Well Diameter < Sealing Material i Depth Q <br /> Depth . Filler Material i Depth <br /> TYPE OF.SEPTIC WORK; NEW�INSTALLATION 0 REPAIRIAOOITION`O—,.DESTRUCTION CI (No septic system permitted if public sewer is <br /> i F. i Y available within 200 lest.) <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 - 0 Type/Mfg Capacity____ No. Compartments <br /> PKG. TREATMENT PLT. Gl } Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. A Length of lines — <br /> Total"lengthlsize- <br /> FILTER BED n `Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth 9 Size Number <br /> SUMPS Ll Distance to nearest: Wall Foundation Property Line <br /> DISPOSAL PONDS 0 1 <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 4 <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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> + The applicant must call fo required inspections. Complete drawing on r erse side. <br /> 4f <br /> Signed Title: -- -•-- Date: <br /> -FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data 1 1Z Area f <br /> ' Pit or Grout Inspection by Date Final Inspection by Date Z <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_0 BOX 2000, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTEO CASH "' RECHVED BY DATE PERMIT No. <br /> INFO frr ��] �/ C _ �[ +� <br /> . £H 13-24WEV.ItA5+ �� Ta''(� T��^ "' 35'.f� -7 <br /> EH 14.26 <br />