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r II APPLICATION FOR RECEIVED PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES SEP 9 1991 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA. 95201 E"d'VIRON MENTAL HEALTH <br /> (209) 468-344? }�E �iv1i /Jt_Rti ICE <br /> PERMIT , IRB 1 YEAR PROM DATE 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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 11 t � � <br /> Job Address --City Lot Size/Acreage <br /> i �� <br /> Owner's Name . o r �� Address Phone <br /> Contractors --Address �. 3a License Phone �1< <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT M DESTRUCTION ❑ that of Service Well 0 <br /> I <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER 0 Monitoring Well L7 <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 WEL'LPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f."} Ind 'al ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omeatic/Private Q Gravel Pack L7 Tracy Type of Casing Specifications <br /> M Public is Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern. urface Seal Installed by <br /> Repair Work Done 0' Type of Pump H.P. f� —- State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material-4 Depth <br /> t Depth Piller-Material i..Depth <br /> !� <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION D REPAIAIADDITION 0 DESTRUCTION 0 (No septic system permitted if public $ewer.is. <br /> 1 available within 200 feet. <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> i Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKC. TREATMENT PLT. 0 Method of Disposal r <br /> J Distance to nearest: Well -Foundation- - - -Property,Line <br /> LEACHING LINE C1 No. & Length of lines t ' -0. 'Toiai-length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> L <br /> SEEPAGE PITS 11 Depth Size Number <br /> t SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS L1 C <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 /> +tome owner or licensed agent's signature Certifies the following: "I certify that in the periofmance 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 /> Ilon laws of California." <br /> The applicant mt r all required ' spe tions, Complete drawing on r rse side. <br /> Signed .. „gam os Tide Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -- Dare Area r <br /> Pit or Grout Inspection by T Date final Inspection by Date n1 l.3 q <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERIIIT/SERVICES <br /> 4145 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE AMOUk7 REMITTED CASH _ RECEIVED BY DATE PERMIT'N0. <br /> . Ek1]-NIREV.Iix51 �AV 4/m � 19/1 , <br /> EN i 416 ✓ I �� <br /> . .a <br />