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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> P.gml.n FIRES 7. YEAR `RODd DATE- ,I SM, 115n <br /> (Complete in Triplicate) <br /> I 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 coarpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ,� � C• Lot Size/Acreage <br /> Job Address 9i <br /> 4 � � n p I J X11 Address Phone 7 <br /> Owner's Name�"� —T <br /> ! Contractor Address <br /> 5 0 License No,5 P <br /> WELL REPLACEMENT C1 DESTRUCTION t of Service We11 ❑ <br /> TYPE OF WELL/PUMP: NEW WELL O Monitoring Well U <br /> PUMP INSTALLATION C] . SYSTEM REPAIR 0 OTHER O <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �—.�- AGRICULTURE WELL - OTHER WELL PITSISUMPS <br /> FOUNDATION �— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing r <br /> C1 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> L-Domestic/Private C1 Gravel Pack ❑ Tracy. Type of Casing <br /> MPublic <br /> 1-1 Other ❑ Delta Depth'of Grout Seal Type of Grout J <br /> G irrigation .._._.Approxi Depth ❑ Eastern Surface Seal Installed by n , <br /> r yf p State Work Done <br /> Repair Work Done U "Type of Pump /O, Sealing Material i Depth 1t <br /> Wall Destruction Well Diameter _A_____r.— <br /> Depth Filler Material "b Depth I��1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION Cl (Nailableo septi system <br /> ithin m ranted if public sewer is It r <br /> installation will serve: Residence — Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Chsractar of soil to a depth of 3 feet: Water table depth <br /> I• Capacity No. Compartments <br /> y <br /> SEPTIC TANK ❑ Type/Mfp"� <br /> PKG. TREATMENT.PLT.C7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1 j <br /> Ff LEACHING UNE $ ❑ No. 8 Length of lines Total lengthtsize <br /> FILTER BED n Distancetonearest: Well Foundation Property Line <br /> s SEEPAGE PITS i 11 Depth ° Sire Number <br /> SUMPS LI Distance to nearest: Wall Foundation Property Line <br /> 1 DISPOSAL PONDS © + <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County <br /> Horne owner or licensed agent's signature certifies the following: "t 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, I shall employ persons subject to workman's compsnsa• <br /> tion laws of California." t <br /> The applican m all for al quired1 inspections. Complete drawing on reverse *ids: <br /> Signed X.G - Title: Data: r - <br /> "EPARTMENT USE ONLY <br /> Application Accepted by <br /> Date � � � Area <br /> Date Final Inspection by ��y—. Date <br /> Pit or Grout Inspection by !// <br /> C�r2o III <br /> Additional Comments: <br /> Applicant - Return all copies to: BAN 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 AMOUNT DUE AMOUNT REfdCASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . FH 13.24 tREv.„M 5) �� D ®� V , <br /> EH 7�•le <br />