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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-aW,t3q-1-" <br /> Y R <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 crwliancelwith Ban Joaquin County Ordinance No. 549 and .1862 and the Rules and Regulations of San <br /> JoKuin County Public Health Servi <br /> Lot Size/Acreage <br /> AJob Address City <br /> lYLi Phone -8.35- <br /> Zg3/3 <br /> )Owner's Nemo _ ���I5e D Q�._ Address <br /> _ I�Y Address License No, _�__�—Phone <br /> Contractor DESTRUCTION Out of Service Well 0TYPE Of WELL/PUMP: NEW WELL ED WELL REPLACEMENT Cl pTHE Monitoring Well C1 <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES -- DISPOSAL FLD. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK ,��� PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �If <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Weil Casing <br /> Type of Casing Specifications <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Grout <br /> Cl Public 1-1 Other © Delta Depth of Grout Seal <br /> n Irfigation Approx.'Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done C3 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter sealing Material A Depth <br /> lZ <br /> � <br /> Depth Filler Material i Depth ' CO <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION fl &AA2Ka <br /> REPAIR/ADDITION L7 DESTRUCTION ❑ availabiNo lerc system wi within 200(e titled if ublie sewer is <br /> t <br /> Installation will serve: Residence d Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of &oil to a depth of 3 feet' Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments L( \ <br /> Method of Disposal <br /> PKG. TREATMENT PLT, Cl <br /> Distance to nearest: Well Found Property Line (� <br /> iV <br /> LEACHING LINE 0 No. & Length of lines To length/size <br /> FILTER BED Ci Distance to nearest: Foundation operty Line <br /> f 3 <br /> Number <br /> SEEPAGE PITS i I Depth Size ! <br /> SUMPS Ll Dis cisto nearest: Well Foundation Property Line J <br /> DISPOSAL PONDS ❑ A <br /> hereby that I havo prepared this application and that the work will be dons in accordance with San Joaquin county ordinances, state laws, and <br /> I csrtif <br /> fY <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 /> f 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, I shall employ persons subject to workman's compensa• <br /> i tion laws of California." <br /> k The applicant must call for all to fired i spections, Complete drawing on reverse side, `/ I <br /> !i Title: Date: <br /> XSigned <br /> OR DEPARTMENT USE ONLY <br /> AlApplication Accepted by Date Area s�1 L4Z <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Commenti: <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 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASN RECEIVED BY DATE PERM17 N0. <br /> INFO –o3 <br /> '. . EM 13-241Rev.findl �� [](] <br /> W�U <br /> EH;t•2a �J <br /> r <br />