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APPLICATION FOR PERMIT YXfL <br /> S <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION a <br /> P O BOX 2009, STOCKTON, CA ,95201 <br /> (209) 468-3447 <br /> R <br /> (Complete in Triplicate) //C�'``/� <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or/ tiallt3sr�}�'!< heit>ts6 bed. This ~ <br /> application is trade in compliance with Ban Joaquin County Ordinance No. 549 and 186 ,*ii. he Rule Regjtl�ft no of San <br /> Joaquin County Public Health Services. Ik/, <br /> r °`O! <br /> � ` A� <br /> n, <br /> Job Address -� �L ` �-- _—__ . City � Lot ste L/ <br /> ' -CO A-" �rC6� elf, - T 7 a <br /> Owner's Name T Add ess __, .. -. w Phon <br /> Conlracfor �� �-c-� 4� Address (D <3 License No& a3?-3 -Phone - 9�6 a� <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 177 DESTRUCTION 0 Dut of Service well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 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 /> ["omestic/Private CI Gravel Pack ❑.T.racy___�___d.7yp _of,casingSpecifications <br /> M Priblic I'1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Depth, ❑ Eastern Surface Seal installed by <br /> Repair.Work Done LJ Type of Pump 1 "- H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> �.' Qepth "�r..^ - - Filler Material-i-Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION M (No septic system permitted if public sewer is <br /> available within 200 feet-1 <br /> Installation will serve: Residence— Commercial Other <br /> Number of living unite: Number of bedroomi <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I . <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS 11 Depth Si:a Number <br /> a <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 <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 San Joaquin County <br /> Home 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 hiring or subcontracting signature <br /> certifies the following: "4 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." i <br /> The applicant s11 I1O1or allr wired ins coons. Camplota''drppawing or! reverse side. <br /> Signed X.__ ' j Date: <br /> F90 DEPARTMENT USE ONLY �J <br /> Application Accepted by Date !"--2419 i Area g;� �� 7 <br /> Pit or Grout Inspection b -b�r ._,1 Date3� �L( <br /> V Date Final Inspection <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 BOR 2009, STOCKTON, CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13•24 IREV.i'iryr5 r �y y Al yo <br />