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APPLICATION FOR PERMIT Alq4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> IIdVIRONw.ENTAL WRAITH DIVISION <br /> 445.N SAN JOAQUIN, PHONE (209)468--3420 <br /> 11P 0 BOX 2009, STOCKTON, CA 95201 <br /> p, M-11 EMPIRES 1 Y FR M D E SUED <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 in 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 /> Lot Size/Acreage <br /> City <br /> AJob Addrsas �- <br /> " #• Phone <br /> Owner's Name s ddress <br /> License No <br /> 449L -201— <br /> --�Contfactor <br /> 1 t9Address . �r� Phone <br /> of Service <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Cl Out Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR CI OTHER ElMonitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> YNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> 0 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation <br /> Type of Casing_ Specifications <br /> [l Domestic/Private ❑ Gravel Pack' 17 Tracy Type of Grout <br /> — <br /> 11 Putrlic !-1 Other 1 Cl Delta Depth of Grout Seal <br /> W <br /> I I Irrigation —.Approx,'Depth I I Eastern Surface Seal installed by <br /> H P State Work pons_ <br /> Repair Work pone U Type of Pump Sealing Material i Depth <br /> Wafl,Destruction; <br /> Well Diameter hiller Material i Depth r„ <br /> v J1 <br /> i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIAOOITION I I DESTRUCTION (Nail a etlw thin 200 feet.) if public sewer is <br /> 4 Insfillotion will serve: Residence Commercial_ ^ Other <br /> -: Number of living units: Number of bedrooms <br /> �. Water table depth <br /> E Character,of soil to a depth of$feet:' <br /> l I Capacity. -.- No. Compartments <br /> SEPTIC TANK�� ❑ Type/Mfg. _ Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance t nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. $ Length of lines Total lengthtsize <br /> FILTER BED 0 Distance to nearest, Well Foundation Property Line <br /> ! <br /> SEEPAGE PITS JI Depth Sire Number <br /> SUMPS _ 0 Distance to nearest: Well Foundation - - - -`Property Line <br /> DISPOSAL,PONDS ❑ f f. <br /> 1 I hereby certify that I have prepared this application and that the work will be done in accordence with San Joaquin county ordinances, state Wws, an <br /> } rules and regulations of the San Joaquin County ' �. -^^- T t <br /> Home ownsr-or-licensed agent's signature certifies the following: "I certify that in the performance of the work for which this:pe mit 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 performsnce of the'work for_which this permit is issued, I shall employ persons subject to workman's compenss- <br /> tan laws of California.,, - - 1- -' � � _ <br /> P, <br /> The applica t ust call efts i do . Complete drawing on reverse side. <br /> --;pSigned Title: "oma _ Date: <br /> FOR DEPARTMENT USE ONLY 16 <br /> T _ Date Z� Area 'L-1 <br /> ' Application Accepted by <br /> Final Inspection by Data <br /> Pit or Grout Inspection by <br /> Date <br /> Additional Comments: C w4s rye <br /> r <br /> 'Applicant - Return all copies to: San Joaquin County Heal is Health Services <br /> Environmental Health <br /> Permit/Services <br /> 445 N San Joaquin, P O BOX-2009, Stkn, CA 95201 <br /> 1 <br /> FEECK <br /> AMOUNT DUE MOUNT REMITTED CAS EIVED BY ATE PERMIT ND. <br /> . EH 13.24 IM, 61 <br /> EH 14.35 r <br /> F; - <br />