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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 /> (Complete in Triplicate) <br /> Application is hereby nade.to San Joaquin County for a permit to construct and/or install the work herein described. This <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 __ . _ CityLot Size/Acreage <br /> Owner's Name % r S 2G t:22 _— Address 6 + tL, Phone <br /> Contractor % S C{-rcjr• Address License No. ��Phone f <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well 0 <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 /> fl Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Grave! Pack n Tracy Type of Casing Specifications <br /> M Public 1'l3 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G Irrigation Appror, Depth C] Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H,P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 13 REPAIR/ADDITION M DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Y Other <br /> Number of living units: Number of bedrooms 55 r <br /> Character of &oil to a depth of 3 feet: .- o(&tov C, R Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ��'L' �S �Se�t1 Capacity. L_ b No. Compartments <br /> PKG. TREATMENT PLT. Cl r Method of Disposal <br /> Distance to nearest: Well (oe Foundation 42 Property Line -f d <br /> LEACHING LINE No. 8 Length of lines 3 —TY 0 r Total length/sire Z 4 <br /> FILTER BED [_1 Distance to nearest: Well Foundation -f- Property Line } <br /> SEEPAGE PITS 11 Depth Size Number !� <br /> SUMPS LI Distance to nearest: Well Foundation Property Line a <br /> DISPOSAL PONDS ❑ <br /> I hereby cartity 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 workman's compensation laws of California." Contractor's hiring or subcontracting 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 /> tion laws of 5f <br /> lifornis,' <br /> The applican must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: ����"-^��' Date: - - -- <br /> R DEPARTMENT USE ONLY f <br /> Application Accepted by ""— Date _a Area + <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO MOUNT DUEAMTAMOUNT REMIf1ED 1i 1CA1'S' H1 RECEIVED BY �DATE_ / PiEAMM11'i(NOO. <br /> . EH 13-24CREV,Irn51 tn <br /> r � l! i� r /p <br /> EH:4.2& <br />