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��r 3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 96241 <br /> (209) 468-3447 ! <br /> YEAR <br /> (Complete in Triplicate) <br /> Application is hereby aide to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1122 City <br /> DL Lot Size/Acreage <br /> - --•— <br /> Owner's Name ' +� Address Phone <br /> Cantrac <br /> C�Addres 3 C License T2� ,-Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 ESTRUCTION ❑ Out of Service Well 0PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> INTENDED USE TYPE OF WELD ,PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Ind al ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ! <br /> Q Public Cl Other ❑ Delta Depth ol-.Groui Seal Type of Grout <br /> r-I Irrigation,' Apprex. Depth Eastern r Surface Seat Installed by <br /> Repair Work Done 'l�" Type of Pump � H.P. t��� �� State Work Done <br /> Well Destruction © Well Diameter Sealing Material i Depth _ I <br /> Depth' Filler Material 1k Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI '(No septic system'permitted if public sewer is <br /> available within 200 feet,` <br /> Installation will serve: Residence— Commercial-- Others; <br /> Number of living units: , Number of bedrooms <br /> Character of boil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well 'FoundationProperty Line � ! <br /> vs � <br /> LEACHING LINE 0 No. & Length of lines Total length/size i <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> I <br /> i <br /> SEEPAGE PITS i I Depth Sire Number -��-�-- -- - � ---4 i <br /> SUMPS LI Distance to nearest: Well Foundation 'L-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 San'Josquin 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, [shall employ persons subject to workman's compensa- <br /> tion laws of California." "' " .'' , <br /> The applicant m all r H required ins actions. Complete drawing o reverse side. t � N <br /> Signed Title: Date: <br /> FOR DEP FITMENT USE ONLY <br /> Application Accepted byDate 7 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 111 Zy <br /> Addition&] Comments: <br /> ,i <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.-BOX 2009, STOCKTON, CA 95201 <br /> tFEE AMOUNT DUE AMOUNT REMITTED CIC #1 RECEIVED BY �J DATE PERMIT NO. <br /> . EH 13,24 11tEV.i/nal vs-.rb p'ZJ <br /> EH i4.2e <br />