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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> r <br /> i.PERMIT EXPIRES I YEAR FROM DAZE IgSURD <br /> (Complete in Triplicate) <br /> Application is hereby made to Sadjoaquin County for a permit to construct and/or install the vork 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. /� ' ( ���y� <br /> Job Address __- —"V Z,Z - '-CctyY/ I C 192 City Ct'� Lot Size/Acreage al/ _ <br /> Owner's Name Address .7Q I�1 Phone <br /> ContracttN' A- 0.-1Address .5 ri ifL License Ngo.f Phone <br /> i TYPE OF WELL/PUMP: " NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTFM�REPAIRX OTHER ❑ Monitoring Well ❑ <br />� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. � PROP. LINE <br /> 1` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation`" Dia. of Well Casing <br /> a i+ <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_- Specifications <br /> I'I Public C7 Other fl Delta Depth of Grout Seal r-�- Type of Grout <br /> rel lrlrrigatlon` _rApprox .Depth- I"LEasterm5urf a.Seel Installed by <br /> Repair Work Done f! Type of Pump H:P - Statq.Work Doone�`r A�' ` r9 <br /> Wall Destruction ❑" Well Diameter,: Sealing Ila rial i'Depth s '64d-L VV�� <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if pu tic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Numbe-.of bedrooms �[ <br /> ' Character of w#to a depth of 3 feat: . <br /> Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg°I ~' Capacity No. Compartments <br /> PKG. TREATMENT PLY. ❑ _ Method of Disposal <br /> Distance 16 nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I I Depth tI Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I / <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 ►v�/}f <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 ths'performence of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call r an r wired inspsctio . Complete drawing on reverse side. <br /> Signed Title: _6YKET.pDate: e <br /> 117 147 <br /> OR EPARTMENT USE ONLY <br /> Application Accepted by Area 5 13 <br /> Pit or Grout Inspection by Date Final Inspection by W Date. `fc�--CC-L— <br /> Additional Comments: r <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> + Environmental Health Permit/Services <br /> 1 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> FEE ZE DUE AM NT REMITTED CA ECEIVEp BY DATE PE <br /> INFO <br /> . EN 13.24IREV.t/eS1IT <br /> EH 14.2! <br />