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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC •HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DTE ISSUED <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 costpliance 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 �v � City 06ZA41 Lot Site/Acreage 3f *^s <br /> Owner's Name �r ll� Address VY41W le A-7 0,1M Phone 6!U-?,?641 <br /> Contractor �r/` " __Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well C7 <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 /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> 11 Public Cl Other 1-1 Delta Depth of Grout Seal Type of Grout �+K <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. t Work =ne r <br /> Well Destruction O Well Diameter Sealing Material i Depth �} <br /> DepthMOP Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOtTION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial T 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLY, ❑ ; Method of Disposal <br /> 'to nearest: ,�Well "{Foundation Property Line <br /> Distance. <br /> LEACHING LINE ❑ No. 8 Length of lines• Total length/size <br /> FILTER BED r❑ . Distance to nearest: , Well Foundation Property Line, <br /> SEEPAGE PITS I:l Depth Size Number <br /> SUMPS 1 SLI_'Distance to nearest: Well-_z_ — Foundation - Property Line <br /> DISPOSAL PONDS ❑ <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 Q` p <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 perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." _ <br /> Thea icant must call for all required i tions. Complete drawing on reverse side. <br /> r` �igned tl �Grdf'/"�'t/i't Date: <br /> ,FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by �xFDate `S ~ 'J Q� <br /> Area 2' <br /> Phor Grout Inspection by date Final Inspection by W Date T <br /> Additional Comments: <br /> _'-"`" Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH `- -REt: VEp BY DATE PERMiT'NO. <br /> ',4 v <br /> . EM 13.24(REV.,i n S! �f t� i � " � go-as - I <br /> Eli 14.26 <br />