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APPLICATION FOR PERMIT <br /> Y� <br /> ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> and/or install the work herein described. This <br /> Applicstion is hereby made,to jam Joaquin County for s'permi <br /> t to construct' <br /> application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> k Joaquin Count 8ervicee. � <br /> City Lot Size/Acreage <br /> ' NC1Qs� _ <br /> Job Address �Q <br /> � !T� Phone <br /> r �O �7 Address <br /> ,Owner's Name Vs <br /> r� License No. Phone <br /> �/ O(,�}N e. v Address <br /> ./Contractor WELL REPLACEMENT ❑ DESTRUCTION ❑ O+it of Service Wei <br /> 1 ❑ <br /> *NEW WELL C1 OTHER ❑ Monitoring Will [7 <br /> TYPE OF WK77OMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ <br /> DISPOSAL FLD.— PROP. LINE <br /> SEWER LINES — 'PITSISUMPS <br /> D15TANCE TO NEAREST: SEPTIC TANK --- -- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL�.�-� <br /> _� <br /> 4 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE Dia. of Well Casing <br /> 0 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation_ Specifications <br /> U Domestic/Private ❑ Gravel C] Tracy Type of Casing Pack Depth of Grout Seal Type of Grout <br /> M Public I1 Other 0 Delta <br /> M Irrigation �.Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ( Repair Work Done U Type of Pump H.P. State Work pone _ <br /> k i Sealing Material L Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth ' <br /> TYPE OF SEPTIC WORK: NEW iN.STALLATION REPAIR/ADDITION C1 DESTRUCTION 0 INo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> installation will serve: Residenceil Commercial Other <br /> Number of living units: Number of bedroomst <br /> S' ( � Water table depth <br /> j Character of soil to a depth of 3''4' <br /> SEPTIC.TANK. ❑ Typa/'Mfg Capacity' U No. Compartments <br /> PKG. TREATMENT PLT. C1 : Method Method off Di gal <br /> Distance to nearest: Well Foundation Property Line ..._ <br /> LEACHING LINE No. &1 Length of lines 106 T IaI length/size <br /> r csa Pro a d <br /> FILTER BED �I Distance to nearest: Well �� Foundation party Line � <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll .Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ it IQ <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: "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 dews of California." <br /> The applicant must=forqud inspecti na. Complete drawing on reverse-side:Signed?C_ Title; Date: �� r <br /> t <br /> F OEPARTfMENT USE ONLY <br /> Application Accepted by ______ \ Lww _ �� Date1 Area <br /> Pit or Grout Inspection by Data Fine Inspection by Date �2 <br /> Additional Comments: I <br /> t <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> EFEEO ' AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> fir <br /> EH 13-24 IItev.1/"of ti I /� l (�. /�•{� <br /> EH 14.26 lir tQZ C 1 ^� L�d to -"%0-B7 <br />