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- r <br /> APPLICATION FOR PERMIT <br /> SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ,,pTR,MIT E ELHES_ I YEAR PRAM UATT ISSUffi? <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �/ /�, e Ao :>-$:ize_Acre e <br /> Job Address "'" `mow City 4014 <br /> / ,f aB <br /> /j /� t'GCJ+� IW I.i //L Y V /y44.r3 7� <br /> G (�llf /,,'J1 'c <br /> Owner's Nams </ d� Address ' � Phone <br /> Contractor. ©�w'�� Address License No. Sl �Phone' U3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCT,ION t of Sorvice well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ '` OTHER O Monitoring well C3 <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 C1-Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> L3 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> 0 Public I'1 Other ❑ Delta Depth of Grout Seal Type of Grout (p k &I; �r <br /> CJ Irrigation �.,� Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H,P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) iiiaaa <br /> Installation will serve: Residence 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. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS II Depth Size Number <br /> SUMPS L1 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: -1 Certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tlon laws of California." <br /> The applican st ca fvr all ro tred inspections. Complete drawing on rea side. / <br /> Signed Title: ._ 95 <br /> pe, „ ,,. C-,t/?�/ Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection Dats� [3 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES / <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCRTON, CA 98201 <br /> FEE INFO MOUNT''DUE MOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> + EM 1,' rREV. i r1 S! ©�iJ C) ,O'� T 4 �9 <br /> rr <br />