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APPLICATION" FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1 ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 999 <br /> (209) 465-3447 Y3=s <br /> � e : <br /> FIRES I YEAR <br /> I (Complete in Triplicate) . <br /> Application is hereby trade"to San]Joaquin.County for a perwit to construct and/or install the work herein described:' This <br /> application is made in compliance.with San Joaquin,County Ordinance No. 544 and 1862 and the Rules Lad Regulations of,San <br /> Joaquin County Public It Services. (�/]f <br /> Job Address <br /> ` ` City�`�`� Lot Site/Acreage i <br /> Address <br /> - . <br /> Owner'/ Name Phoneme t <br /> 2 <br /> Contractor Address Q License No Phone' , <br /> i TYPE OF WELL/PUMP: IV NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REP D OTHER ❑ Monitoring Wall=� <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> l FOUNDATION, AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREAA!— <br /> N SPECIFICATIONSLl Industrial ❑ Open Bottom ❑ Manteca cavation 4 Dia. of Well GeeingiU DomesticIPrivoe 0 Gravel Pack 0 Tracy Specifications <br /> Ili Public 11 Other ❑ Delta 5al-- _ !Type of Grout 4�CJ Irrigation _ Aptxox, Depth ❑ Eastern stalled by \ <br /> Repair Work Done U Type of Pump H.P; State Work•Dons <br /> tWoll Destruction ❑ Well Diameter <br /> Sea ing Material A Depth l t <br /> Depth ! Filler"'titaterial i. Depth ' <br /> ;TYPE OF.,S�EPTIC WORK�_.NEW"INSTALLATION REPAIR1ADCATION O DESTRUCTION G iNo septic system permined if public sewer is.. 11q, <br /> _ <br /> available within200 feet.) r <br /> 1 Installation will serve: Residence .r Gommerciel <br /> ' <br /> Numberof living units: Number of bedrooms <br /> Character of &oil to a,depth of 3 feet: ;..! /Water table depth <br /> 'SEPTIC TANK. ❑ Type/Mlg Capacity No. Com partmenta i <br /> PKG. TREATMENT PLT. 0 s Disposal <br /> � r Method of Di oaal I � <br /> Distance tofnearest: Well ) _Foundation �_l, Property Line ' <br /> LEACHING LINE ❑ No. 8 Length of lines ` To al length/size <br /> -FILTER BED; ❑ Distance tornearest: Well n• r v"- Foundation 1,) Property Line <br /> J <br /> SEEPAGE'PiTS II Depth Sire Nu b C 9t <br /> sumps i ; L1 Distance tonearelFt, Well V Foundation Property Line,'i <br /> DISPOSAL PONDS ` ❑ ! <br /> I hereby eenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Caws, and <br /> rules and regulations of,the Sen Joaquin County <br /> Home owner or licensed agent's signature Certifies the following: "I Certify that in the perlormance of.the work for which this permit is issued, I.shall not <br /> imptoy any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for wh+ch this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion Caws of California.'; <br /> The appficant st call'for ail r trod inspo, tions. Complete drawing on reverse side, <br /> Signed .Title: �L-C/`"T�"'�t ,. Date: i <br /> i FOR DEPARTMENT USE ONLY <br /> Applicauon',Acceptedby f�1r$—• N-� Date Area <br /> 1 �D <br /> Pit or Grout Inspection by Date Final Inspection bDate <br /> e is - <br /> Additional Comments r i. <br /> Applicant - Aeturc all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> 4 ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> .;.. i <br /> 445 N SAN JOAQUIN, F O BOX 2009, STOCKTON, CA 95201 <br /> j FEE AMOUNT-DUE AMOUNT REMITTED CASH -• <' RECEIVED BY' -DATE ' " " -PERMIT NO. <br /> ( _r_ .INFO- <br /> � . <br /> tK 17.24 IACV, s, r� Au_ _ S• T f <br /> EN 14.71 <br />