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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in Triplicate) <br /> r 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 Ban <br /> Joaquin County Public Health Services. <br /> �,�`Jp� Cit Lot Size/Acreage <br /> Job Address � � � -� <br /> 1a' Address ✓G Phone <br /> Owner's Nates SERVICE �} -596 <br /> P.O. BOX 602 LINDEN, CA 952 License NO. Phone 1 <br /> Contractor rase <br /> WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION LI of Service Well <br /> TYPE OF C1 <br /> i monitoring well C7 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICUITUP.E�WELt OTHER—WELL PITS/SUMPS - <br /> _ ---_ - _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> rl Industrial O Open Bottom ❑ Manteca Dia, of Well Excavation <br /> g <br /> Type of Casing Specifications• <br /> �.pomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Grout <br /> R Public Cl Other ❑ Delta Depth of Grout Seal <br /> C-i Irripstion Approx. Depth ❑ Eastern Surlace Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work pone _ <br /> rti <br /> Well Destruction O Well Diameter _.d,...�..— . Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> ermitted <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JDREPAIRIADDITION CI DESTRUCTION CI availablerwthin 20stem 0 .)feetit public sewer is <br /> Installation will serve: Residence— Commercial Other <br /> Number of living unite: Number of bedrooms PAYMENT <br /> I Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT.C1 ��"12is, <br /> Distance to nearest: Well Foundation Pro%W, TY <br /> PLJBI IC HFAI 1H RV I CE_S_ <br /> LEACHING LINE 0 No, B Length of lines ToialgWJJQVNENTALHEALIH DIVISION <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI i3Distance to nearest: Well Foundation Property Line <br /> DISPOSAL <br /> herebyrreby certiffyhthat I have Iprepared this application and that the work w II be done in accordance with SanJoey aqu county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the lollowing: "I certify that in the performance ria the work for which this permit is issued, I shall rt e <br /> employ any person in such manner as to become subject to workman's compensation laws <br /> j of California." Contractor's hiring or sub contracting signature <br /> certifies the following: "I certify that in the performance of the workJor which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." f <br /> I The applicant all for all (jAuirelf inspections. Complete drawing on reverse side: <br /> Signed Title: ` Y Date: <br /> FO DEPARTMENT USE ONLY <br /> I <br /> ' <br /> U.r. r; y. _ 3��4� Area___SL. A --— <br /> Application Accepted by Date <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> . <br /> EH 13 cQtJ 43 <br /> V- <br /> EN 14.26 <br />