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k <br /> APPLICATION FOR PERMIT <br /> R97CEIVED , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION APR 1 1 1991 <br /> i.P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> ,} (209) 468-3447 . . .PERMIT/SERVICES <br /> PERMIT WMIRM 1 YEAR rROM DATE ISSUED ! ti <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam Voaquin 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 r�i ©�I - City of Size/Acreage <br /> i <br /> Owner's Name Address Phone <br /> C c� of <br /> Contractor ddress�� ��f �c- �`3� icense Ivo. �3 p�Z Phone4�' <br /> TYPE OF WELL/PUMP: NEW WELL. Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ! OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE Y J <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 7;4omestic/Private Cl Gravel Pack ❑ Tracy Type of Casing. Specifications <br /> M Public I'1 Other ❑ Delta r Depth of Gr6ut Seal Type of Grout <br /> CJ Irrigation _.Approx. Depth ❑ Eastern1 Surface Saul Installed by <br /> Repair Work Done "Type of_Pum_p a H.P.Z � State Work Donee ! <br /> Well Destruction ❑ Well Diameter Y Sealing �1riwl i Depth r 4 <br /> tFiller Material III Depth <br /> 11 <br /> Depth <br /> • -�3 a <br /> — TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION 0 DESTRUCTION M INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> t Y <br /> Installation will serve; Residence..,_;I Commercial— Other IV <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg .i ! °— Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 1 ' ' Method of Disposal <br /> Distance to nearest;# Well Foundation Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS LI Distance to nearest: Well Foundation a Property LineDISPOSAL.PONDS- ❑ <br /> 1 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: "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 California." ` , ' <br /> The applicant must squired ins <br /> ct' ns. Complete drawing on reverse side'. <br /> Y <br /> 1. <br /> Signed X_ Title: 02 41 - _.__ Date: <br /> FOJVDEPARTMENT USE ONLY / <br /> k �/ � <br /> Application Accepted by Date Area Q <br /> Pit or Grout Inspection by Date Final Inspection by Date �3 Z <br /> Additional Comments. — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> p <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br />` :445 N SAN JOAQUIN, P O BOX 2008, STOCKTON. CA 85201 <br /> f FEE AMOUNT DUE i AMOUNT REMITTED CEIVED BY DATE PERMIT'NO, <br /> INFO CAA SH'' -. REyf�j�� (/� <br /> EN 17.24 t 11 Ev.It R 51 `� \ ' , la - <br /> E <br /> EH^4.2s <br /> 1 <br />