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v <br /> APPLICATD.. 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 /> _R9 -ATE ISSU <br /> Y R <br /> ,I (Complete in Triplicate) <br /> t <br /> Application is hereby made to Sea Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin ounty Ordinance No. 549 and $62 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi ee <br /> r City a Lot Site/Acreage <br /> Job Address <br /> 4 �,.r._ PhoneAr k <br /> Owner's Name Address <br /> I, <br /> _ I: <br /> Contractor i i Address sn License <br /> OFFWELL/,PUMP: NEW WELL © WELL REPLACEMENT CI DESTRUCTION Ll Out of service well U <br /> PUMP INSTALLATION C1 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well p�., <br /> DISTANCE TO NEAREST_ _SEPTIC TANom-�` SEWER LINES DISPOSAL FLD; PROP. LINE <br /> FOUNDATION z AGRICULTURE WELL t OTHER WELL PITS/SUMPS <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 /> V'Domestic/Private 0 Gravel Pack ❑ Tracy_ Type of Casing Specifications <br /> 111 Public I'1 Other E3 Delta Depth of Grout Seal Type of Grout <br /> 0 Irr patlon Approx• Depth Eastern �rfaee Saul Installed by <br /> Repair Work Done Type of Pump, H,P. State Work pori <br /> Well Destruction O Well Diameter <br /> Sealing Material & Depth <br /> Depth 'i Filler Material 4 Depth <br /> 1 <br /> TYPE Of SEPTIC WORK:/NEW INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION CI INo septic system permitted if public sewer is <br /> available within 200 feet.f <br /> Installation will serve: Residence #Commercial— Other. <br /> Number of living units: `' Number of bedrooms l4 <br /> Character of soil to a depth of 3 feet: 'r '� i` r Water table depth <br /> �.. ,. . <br /> SEPTIC TANK. ❑/Type/Mfg- " .`.� CapacitNo. Compartments <br /> PKG. TREATMENT PLT. ❑ "� -- - Method of Disposal <br /> Distance to nearest: Well Foundation tProperty.Line <br /> LEACHING LINE ❑�No. 8 Length of lines . Total length/size <br /> FILTER BED n Distance to neareit:"`"" Wiii" Foundation Property Line 4 <br /> SEEPAGE PITS I I { <br /> � Oepth _Siri Number <br /> SUMPS LI Distance to nearest, Weli Foundation Property Line <br /> DISPOSAL PONDS ❑ _ ; <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 Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the periormance 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 c4m n6a• <br /> 'tion laws of California." <br /> The apph72. <br /> st call for all required i ction Complete drawing arse side. <br /> Signed Tide: P _ Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> z <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 AMOUNT DUE AMOUNT REMITTED) CASH RECEIVED BY DATE PERMIT'N0. <br /> INFO tr ff /[� {nom <br /> + EH 13•]4 EV, /n 31 ��1` ,•J ( - < � <br /> EH 1,,4.16 111 <br /> s <br />