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i <br />' x APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL IiEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> I PERMIT EXPIRES 1 YEAR PROM DATE Iamm <br /> (Complete in Triplicate) <br /> Application Is hereby made to San Joaquin County fora permit to construct and/or install the work herein described. This <br /> application is mode in cwvliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of flan <br /> Joaquin County Public Health Services. <br /> .lob Address � - g City Lot Size/Acreage <br /> ti <br /> i <br /> Owner's Name . AM;.4�ddress Phone <br /> s- f <br /> Contraclorr� - Address 8 go icense No. 3��Z Phone ae' <br /> TYPE OF WELL/PUMPS NEW WELL ❑ WELUREPtACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L$. OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_7 Industrial ❑ Open Bottom 0 Manteca Dis. of Well Excavation Dia. of Well Casing <br /> Vmastic/Private 0 Gravel Pack ❑.Tracy Type of Casing Specifications <br /> ❑ Public CI Other ❑ Delta Depth of Grout Seat Type ofMGrout <br /> M Irrigation _.Approx. Depth 0 EasternSurface Soul Installed by '#I <br /> Repair Work Done Type of Pump. H.P. I State Work Done <br /> Wall Destruction O Well Diameter staling Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl REPAIRIADDITION M DESTRUCTION ct tNo septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth- <br /> SEPTIC TANK ❑ T <br /> ype/Mig Capacity No. Compartments <br /> PKG. TREATMENT PLT. +rl Method of Disposal �?' <br /> ---- Die to nearest: 11Vefl _Property Line <br /> LEACHING LINE C} No. & Length of lines s i Total length/size 4 <br /> FILTER BED' r-I Distance to nearest: Well l Foundation Property Line <br /> l SEEPAGE PITS 11 Depth Sire E Number <br /> ' J <br /> ,SUMPS C= Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> r "t. <br /> I hereby certify that I have prepared this application'and1hat-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 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 /> 1 'tion laws of California." . ' <br /> The applicant must call f r alt rs uired lions. Complete drawing on ► rse side. <br /> Signed Title: ��r-"T <br /> U � <br /> FOR ARTMENT USE ONLY <br /> kl Application Accepted by s <br /> Data Area <br /> _ r <br /> ` Pit or Grout Inspection by Date Final Inspection by Date �/ d <br /> Additional Comments: <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> t, iNFE AMOUNT DUE AMOUNT REMITTED �CASHx•-- RECEIVED BY DATE PERMI7'NO. <br /> EH 13 24(1rEV.,i++s) V► VY l �-/t 1 `1Ltv C P— Son <br /> EH 14Ia <br /> , <br />