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T 1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONliiENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 2ERHIT EMPIRES I YEAR rROAL DAZE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in CwWliance with San Joaquin County Ordinance No. 51+9 and 1 62 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> 1 <br /> Job Address 4 ! f f� ��rl .S lr` City i40 Lot Size/Acreage <br /> Owner's Name d 1/�? I +'& Y J Address ke- c Phone <br /> Contractor !_�_fl Address ,Le ./ Y4 ne License No d PhoneV +� <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well G7 <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 0 Manteca Dia, of Well Excavation_ .. Dia. of Well Casing <br /> �)<Domsstic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> a) Public is Other © Delta Depth of Grout Seal Type of Grout JJJ <br /> M Iffioation —,Approx, DepthEastern Surface Seal Installed by <br /> Repair Work Done 1 Type of Pump H.P. f State Work Done <br /> Well Destruction 'O Well Diameter Sealing lfeterial i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G INo 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 foil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue Number <br /> SUMPS LI 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, 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 wofkman'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 tot which this permit is issued, I shall employ persons subject to workma 's compensa- <br /> tion laws of California." <br /> The applic II for all required ins pe s. C plate drawing on 19a4a side. <br /> Signed - Title• �1�� Date: <br /> BPARTMENT USE ONLY Lt <br /> Application Accepted by Date �� Area 3 <br /> Pit or Grout Inspection by Date Final Inspection by-f Vll- _ Date <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 /> FEE K 11 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH U-741 REV. <br /> EH 14•m 4 1 <br />