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-�* APPLICATION .FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ul Z MIT MIRES I YEAR ?ROM DAIS ISSUED <br /> (Camplete, ia Triplicate) <br /> Application is hereby made to San Joaquin County for a perrdil to construct and/or install the work herein described. This <br /> I; application is made in coospliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> I Joaquin County Public Health Service . <br /> Job Address 'd Cit Size/Acreage <br /> Owner's Name Address Phone <br /> r _ _ <br /> ContraAddreAS'-' License t x+910�Phongl_ <br /> TYPE OF WELLIPUMP: NEW WELLLA ❑ WELL REPLACEMENT C_l DESTRUCTION Ll Out of Service Well Gl <br /> PUMP INSTALLATION' SYSTEM <br /> _ REPAIR C7 OTHER ❑ Monitoring Well !3 <br /> OISTANGEtTO NEAREST: SEPTIC TANK_ --- . :SEWER LINES --- _- DISPOSAL FLO. PROP. LINE. <br /> FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS _a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Ind lel ❑ Open Bottom ❑ Manteca t Dia. of Well Excavation Dia. of Well Casing <br /> omeatic/Private t❑ Gravel Pack 0 Tracy w Type of Casing Specifications <br /> ID Public l-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> MI trntjation Approx. Depth ❑ astern SSurface Sedl Installed by <br /> Repair-Work Done (W Type of Pump H.P. If State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth' Piller Material g Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADOITION 0 DESTRUCTION CI (No septic system permitted if pubk1sewer is <br /> available within 200 feet.) <br /> \ . t <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of$oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg CapacityAr <br /> . � tttents <br /> PKG. TREATMENT PLT, ❑ f q +. oaal <br /> ., Distance to nearest: Well Foundation <br /> LEACHING LINE 0 No. A Lengthbf-lines <br /> FILTER BED CI Distance to nearest: Well Foundation ' Inb' S'' 4� <br /> SEEPAGE PITS 11 Depth Silo Number <br /> SUMPS _ Cl Distance to nearest: _Well 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 <br /> rules and regulations of the San'Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I cartify 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." X <br /> The applicant for all req inspections. Complete drawing on arse side: <br /> SignedTitle: 2� ' <br /> -v _ Date: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Areae <br /> Pit or Grout Inspection by Date Final Inspection b Datsl7o <br /> Additional Comments: <br /> W <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P••0 B 08, STOCKTON, CA 85201 <br /> FEE - + I <br /> INFO �JA,M��OUNT DUE AMOUNT REMITTED � ASND/ REGEIVEp BV D"ATA PERNt1T'NO.. <br /> • EH 1]•N IREY.F/MSI �f\ f �/{/ ��� <br /> EH 114-Mfff��v f <br />