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APPLICATION FOR PERMIT <br /> w SAN JOAQUIN COUNTY- PUBLIC HEALTH SERVICES <br /> *r ENV Y�tONlifiENTAL HEALTH D I V-I S I ON <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> a (209) 468-3447 <br /> pZUIT Ugligga 1 'YEAR FROM DATE Ila ED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described.''.This <br /> application is made in compliance vitb,San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 0 <br /> Job-Address __ ( } �` `"" T City Lot Size/Acreage /6 <br /> Owner's Name �- t# ddress � - �Phone <br /> Contractor"� Address -s 3'��' � �C¢ 'cense NoS3 6C 72-Phone 74'A <br /> TYPE OF WELL/PUMP: NEW WELL 9€Y WELL REPLACEMENT:Fm DESTRUCTION Cl Out of Service Well ❑ <br /> ilk <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER 1-3 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,ISa PROP, LINE,—b <br /> FOUNDATION AGRICULTURE WELL OTHER WELL a� PITS/SUMPS <br /> INTENDED USE TYP F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Indus ial pen Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing 4111, <br /> omestic/Private. ❑ Gravel Pack L7 Tracy Type of Casing ,specifications <br /> M Public Cl Other CJ Delta Depth of Grout Seal O r > Type of Groutrl-22�<< <br /> lir gation Approx,.'Depth Eastern Surface Seal Installed by <br /> Repair Work Done- 01* Type of Pump H.P. State Work Done _ <br /> Well Distruciion O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L7 DESTRUCTION M (No septic system permitted if ptiblic sewer"is`" <br /> . i available within 200 feet.) <br /> Installation will-serve: Residence^ Commercial— Other ArE� <br /> _ Number of living units: Number of bedrooms <br /> . :•-Character of soil to'a.depth of 3 feet: <br /> SEPTIC TANK ❑ Typo/Mfg Water table depth} <br /> ` Capacity � 'No. Compartments e <br /> PKG, TREATMENT PLT.Cl Method of Disposal <br /> Distance to nearest: Well { Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines i Total length/sire F - <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number n <br /> _SUMPS L1 Distance to nearest: Well 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, iin(. <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 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." T <br /> The applicant call equired.in'speetions. Complete drawing'on reverse side: <br /> t <br /> Signed Title: Date: <br /> Or <br /> t <br /> . FOR DEPARTMENT USE ONLY r� q <br /> Application Accepted byDare v1- _1 - Area .2, <br /> Pitrout In tion by Final Inspection by Date 13 <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 0 BOX 2009, STOCKTON, CA 95201 <br /> i <br /> NFE AMOUNT DUE AMOUNT REMITTED CK It <br /> ASH RECEIVED BY DATE " PERMIT'NO, <br /> �Q{rte , w <br /> + EN 13241REV.t/n Si ...� <br /> q ? �, 7 <br />