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k <br /> APPLICATION 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 /> PERMIT EXP I RES 1 1EM FROM DAT9__ISSUED <br /> (Complete, in Triplicate) <br /> Application is hereby made to San Joaquin County for a.permit.to construct and/or,inatall the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Service <br /> Job Address �G t9City Lot Size/Acreage <br /> Phone <br /> Owner's Name e- Address <br /> t �. <br /> r _ <br /> Contractor 1 I Address icense No. Ph one, <br /> TYPE OF WELL./PUMP: NEW WELL ❑ - WELL REPLACEMENT ❑ DESTRUCTION ` .Out of Service well ❑ <br /> t <br /> PUMP INSTALLATION ❑ - - - SYSTEM REPAIR D OTHER ❑ Nonitoring Well C] <br /> t #DISTANCE TO NEAREST: SEPTIC TANK # SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL, 'OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF`WELL " Pf�OBLE t AREA -CONSTRUCTION SPEC k kTIONS <br /> Cl Industrial ❑ Open Bottom Cl Manteca Die. of Well Excavation Dia. of Well Casing <br /> (:l Domestic/Privet* O Gravel Pack- ____0 Tracy Type of Casing_ Specifications <br /> Il Public (:1 Other �; n Delta""- ` -Depth of Grout Seal - Type of Grout <br /> I I Irrigation _ lh <br /> Approxi Depth� 4 ISI Eastern ; Surface Saul Installed by �{ <br /> Repair Work Done ❑ Type of Pump" KP. � _ Stat ;Work Done <br /> Well Destruction Well Diameter �� r _Sealing listerial i.Depth^ c <br /> Depth e2 Filler lifrL rial i Depth cg; rCd' "log <br /> .TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public same► is <br /> �' available within 200 fee1.I s' <br /> Installation will serve: Residence— Commercial Other € '" p <br /> Number of living units: ===—Number of bedrooms � <br /> Character of will to a depth of 3 feat: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ``-Capacity No. Compartments <br /> PKG. TREATMENT PLT.C1 f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t � /<-► i <br /> LEACHING LINE Ct I'No. b Lengthtof lines �... Total length/size <br /> FILTER BED _ ❑ 6;Distsnce to nearest: Well Foundation Property Line -- <br /> SEEPAGE <br /> PITS � I I Depth Size Number <br /> -SUMPS` i ''' f a Ll Distance to-nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ra . <br /> I hereby certify that I have prepared this ipplication 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-Cotu'sty <br /> Haire 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 <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hifing 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Xl d� Title: ! Dete: . <br /> A OR DEPARTMENT USE ONLY ~ <br /> Application Accepted by Date —1 Area 1224 <br /> i Pit or Grout Inspection by Date Final Inspection by Date W <br /> I ' <br /> Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 85201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED BY PATE PERMITNO. <br /> « EEH 14-m H 1}24(REV.r/K 6) D �O �l 7 <br />