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APPLICATION FOR P IT <br /> SAN JOAQUIN COUNTY -'PUBLIC HEALTH SERVICES :4 <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 46$-3447 <br /> PERMIT E%PIRES I YEAR_?RQX DATE- ISSUZ 1 <br /> (Complete in Triplicate) i <br /> Applicstiou is hereby made•to Sea Joaquin County for a permit to construct and/or install the work herein described., This i <br /> application Is made 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 /> Job Address 7 ! City " `' Lot Size/Acreakea <br /> Owrier's NameU Address Phone <br /> �� <br /> Contractor Rlp���T Address ��r � �/ IC, License tufo Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well i7 yyyy <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'INELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia, of Well Casing <br /> i <br /> U Domestic/"Private 0 Gravel Pack 0 Tracy Type of Casing Specifications � <br /> p Public l 1,Other ❑ Delta Depth of Grout Seal Type of Grout 44 <br /> 0 Irrigation � 'Approx, Depth ❑ Eastern Surface Sadl Installed by N <br /> Repair Work Done U Type of Pump H.P. —_ State Work Done _. <br /> Wait Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth 0 ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION Cl DESTRUCTION M (No septic-system permitted if public sewer is 1, r. <br /> available within 200 feet.) <br /> installation will serve: Residence-I. Commercial_^ ther T' 1 kj <br /> Number of living unity. Number of bedroo s e <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg c6paciu No. Compartments T <br /> PKG. TREATMENT PLT. 0 ' C Method of Disposal <br /> Distance to nearest: Well Foundation. ���Property Lina �nkp}�r <br /> LEACHING LINE No. 8 Length of lines — 77 Total length/size <br /> FILTER BED 0 Distance to nearest: Well , 2' 21y- Foundation /Z� Property Line /fns T <br /> SEEPAGE PITS it Depth / Si.. j Number *� <br /> SUMPS Distance to'nearest: Well ku,tTY` oundation! Property Lina <br /> DISPOSAL PONDS Cl <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 workrnan',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 compenss- <br /> lion laws of California." <br /> r The applicant must call f all required inspections. Complete drawing on r rse side. <br /> Signed Title: , = --- -- Date: -12�—, <br /> FOR DEPARTMENT USE,ONLY <br /> Application Accepted by 0-zl <br /> Date �f Area <br /> Pit or Grout Inspection by- Date Final Inspection eyis_-:7 <br /> Additional Commenti: <br /> 52L—L <br /> Applicant, - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION-PERYIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE A OUNT REMITTED CK RECEIVED BY DATE PERMIT'N0, <br /> :INFO CASH <br /> . EH 13.24 IREV. i 6) Stq at) <br /> EH <br />