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;. APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> v <br /> YEAR <br /> j " (Complete in Triplicate) <br /> Appiication 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 c=Wliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> E Joaquin County Public Health Services. . <br /> Job Address L T1 City �L Lot Size/Acreage <br /> Ow is Name Address -7Phone v f I r , <br /> f <br /> '"License No. 0-6 Phone ' <br /> k TYPE OF WELLIPUMP: NEWWE%LL ❑ WELL REPLACE ENT ❑ DESTRUCTION ❑ Out of Service well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Q Monitoring 41e11 <br /> PUMP INSTAL�� ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - -AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> p_..6.,_-_-INTENDED"USE .;-TYPE OF WELL- PROBLEM AREA-� CONSTRUCTION-SPECIFICATIONS <br /> r n I ustriai �T❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mesticlPrivate ❑ Gravel Pack El Tracy Type of Casing Specilications <br /> Q Public f.1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> CI Iffigation Appror. Depth Eastern f urface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. - State Work Done <br /> Wall Destruction ❑ Well Diameter I lox <br /> Sealing Material i Depth <br /> a Depth <br /> J filler Material`&'Depth ` } / <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION O REPAIR/ADDITION 0 DESTRUCTION M INo septic system permitted if public er is <br /> available within 206 feet.) <br /> Installation will serve Residence r 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 ❑ Type/Mfg ..Capacity No Compartments <br /> _ PKG, TREATMENT PLT.❑ �� Method of Disposal n <br /> Distance to nearest: Well Foundation Property Line ►� J <br /> LEACHING LINE ❑ No. & Length of lines - Total length/size (� <br /> j FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS LI Distance to nearest: Well Foundation .Property Line <br /> DISPOSAL PONDS 0 r <br /> I hared canily that I have prepared this application and that the work,will be d_one_in_accocdance with San Joaquin.county-ordinances-,state laws;ander <br /> *rules-and-regulations,of-thb Sari Jbegti'in County <br /> Home owner or licensed agent's signature certifies the following: in'the performance of the work far which this permit is issued. I shall not <br /> employ any person in such manner as 6 become subject to wort marl's compensation laws of Calilornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that_in the perfoff�ance;6l_the wdrk_for which this permit is issued, I shall smx0oy'porsons subject to workman's <br /> compensa-tion laws of California." <br /> The applica uat I f r all_. iredinspections Complete drawing on taw sa side. <br /> Sign ��" Till �� a. Date: I ' <br /> F RDE RTMENT USE ONLY <br /> Application Accepted by Date AreacA <br /> IV <br /> , - � - <br /> Plt or Grout Inspection by Date Final Inspection by �� -��/�'s�ilGr'^.�� Data <br /> Additional Comments: _-.__._ _. __,.,.____.__,_. �� �, <br /> Applicant - Return all oopies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL "'ALT' DIVISION-PERMIT/S'RVICEB <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 ►` <br /> )FEENFO AMOUNT DUE AMOUNT_EMITTED CK <br /> R'ECCEIIVED BY DATE` PERMIT"NO. <br /> . EH13-24IREV.1inal <br /> EH 1.4-28u MI . ++ <br />