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APPLICAA-ON-`FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT EXPIRES-1 YM FR N DATE S <br /> (Complete in Triplicate) <br /> Application is hereby made,to &an Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is Stade in compliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San <br /> ` Joaquin County Public Healtil perviies. <br /> 1 t <br /> F . <br /> Jab A rays City Lot Size/Acreage <br /> ._ <br /> LIXXon <br /> I 0 ner's Nam r /A �[] <br /> F p 0 a /4hon� <br /> se No. r(o�- <br /> C r <br /> TYPE OF WELL/PUMP: $ W LUWELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> e Monitoring Well ❑ <br /> PUMP'INSTAALLATIO 1 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES t DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f G7 1 ustn"I © Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> mastic/Private Cl Gravel Pack ❑ Tracy Type of Casing_, Specifications— <br /> `l"1 Public CZ Other _ fl Delta ���111 Depth of Grout Seal Type of Grout <br /> r <br /> 11 Irrigation Approx. De I I stern Surface Said Installed by <br /> f Repair Work Done [J Type of Pum H. State Work <br /> Well Destruction ❑ Well pia ter <br /> Sealing Material i Depth <br /> Depth Piller Material A Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I iNo septic systhin m pe0 1 rmitted if public sewer is <br /> availableInstallation will serve: Residence—.. Commercial_ Other <br /> Number of living units: Number of bedrooms k <br /> Character of wA to a depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity No. Compartments <br /> 1 <br /> � PKG. TREATMENT PLT.Ll Method of Disposal � <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No. B Length of lines Total-length/size (, . <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth Sue Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <br /> rules and regulations of the San Joaquin.County ' <br /> Home owner or licensed agent's signature canities the following: "I 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' "fy that in,the performance of the work for which this permit is i ed, I shall employ persons subject to workman's compensa- <br /> tion lews C 'forma.. _ ., t, •. T__ <br /> The appl" ust call f ed in actions. Com late drawingTon r rse ills. <br /> S. T Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> ! Pit or Grout Inspection by Date Final Inspection by 4 Data / <br /> Additional Commants: <br /> s Applicant - Return all copieS 'to: San Joaquin County Public Health Services <br /> ` Environmental Health Permit/Services <br /> 445 N San Joaquin, P x 2005, Stkn, CA 85201 <br /> � M <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RE EIVED BY _DA7E PERMIT NO. <br /> INFO <br /> . EN 53.24 IItEv.t/w 5 <br /> EN 14•la <br />