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� rr/ <br /> APPLI CATI,ON•.FOR4PFRHI T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> [l►- c. R <br /> ?ROM DATE <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 /> Job Address��� i, �.�+ ` _— City �y Lot Size/Acreage <br /> c <br /> Owner's Namekov- r c Address fes✓-' Phone <br /> Contractor Addles �d+� License No. Phone C�! <br /> TYPE OFrWELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications ri <br /> M Public C1 Other ❑ Delta Depth of Grout Seat Type of Grout <br /> 10 Irrigation _Approx. Depth Q Eastern S ace Seal Installed by Ift <br /> Repair Work Done ' Type of Pump H.P. State Work Done Eiazz Z, <br /> Well Destruction ❑ Weil Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth ' <br /> C, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 feet.) <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE C1 No. B Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Pfopeny Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS 0 ` <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 cenities 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: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa• <br /> tion laws of California." <br /> The applies st c I for all required ins ons. mplete drawing on reverse side. <br /> Signed Title: __ ///;i�/�?Z <br /> �E i Dais: <br /> FO EPARTMENT USE ONLY 1' <br /> {� R 1�. <br /> Application Accepted by al VS(�ga 4 �e(1r`� Date t k_ }Area I If <br /> Pit or Grout Inspection by Date Find Inspection by Date 3 g <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> IFEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT.No. <br /> r EM 15-24 IitEV.i/H5S <br />