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APPLICATION FOR PERMIT <br /> v <br /> r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> _PERMIT EXPIRES 1 YEAR PRQX DAM-MUM <br /> (Complete in Triplicate) <br /> AWication 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 <br /> Public Health Services. <br /> Job Address -?'� / 3 �� /JZJJ -- Cit t Size/Acreage <br /> Quo/ dress, <br /> wner'a Name - - Phone <br /> Contractor I ��dr ice No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 121' OTHER ❑ Monitoring Well E� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SLUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �`mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specilications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> Ca Irrigation Approx. a ern Surface Seal Installed by <br /> e <br /> Repair Work Done D Type of Pump P. it or sone 91 491 <br /> Well Destruction ❑ Well Diameter ��_ Sealing Material & Depth <br /> Depth 93 Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAMIADDITION 0 DESTRUCTION Cl INo 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 6 <br /> Character of soil to a depth of 3 feet:` �' Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments c ' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal V <br /> Distance to nearest:; Well Foundation Property Line <br /> LEACHING LINT: ❑ No. & Length of lines Total length/size li ' <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth - Size Number <br /> SUMPS LI Distance to nearest, Well Foundation Property Line <br /> DISPOSAL20NDS—C] r ��._ d <br /> I her 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 f <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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> lion laws of California." <br /> e <br /> The applica ��stt call or quir ins actions, Complete drawing on re se side. <br /> Sign d ..f3��/ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A�KDated Area �r <br /> Pit or Grout Inspection by Date Final Inspection by - ✓,- Date 3 <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 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT FiEMITt'ED CA RECEIVED BY DATE PERMIT'NO. <br /> 5 EH 13.24 MEV.sins) —C;7� Qom] <br /> EH ti•2a � 1 lJ— <br />