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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 /> YEAR 91ROM PATE 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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County <br /> Public Health Services. <br /> Jobf dAgess _' v�-,� �S_ Gri— VI!2 _ City Lot Size/Acreage <br /> Owner's Name `►n �td ss Phone T f <br /> Contractor /A )i�!tt,-L jf4& Address L icense N . Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �_ 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public I-1 Other ❑ Delta Depth of Grout Seal Type of Grout \ <br /> M Irrigation Approx, Depth ❑ Eastern Surface Seal Installed by �\J <br /> Repair Work Done Ll Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION PAIR/ADDITION LI DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �� available within 200 leat.l <br /> Installation will serve: Residence— Commercial ��Others <br /> Number of living units: Number of b ro ms <br /> Character of $oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Gl fat 51E7__ Of Sp Tr ft <br /> �. Method of Di sale <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Sire Number \� <br /> SUMPS LI Distance to nearest: Well Foundation Property Line ✓���] <br /> DISPOSAL PONDS ❑ <br /> l 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 subcontracting 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 la California." <br /> Thalicantsell of drawing on r arse side. ` <br /> Signer Title: �[ Date: <br /> t­—�OR.OkEPARTMENT USE ONLY qq <br /> Application Accepted by Date ��q�' Area <br /> Pit or Grout Inspection by Date Final Inspection by /4f I' ata <br /> Additional Comments: _ <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 85201 <br /> INF <br /> FE OUNT DUE UNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . E 2 [1019V,tn5i 11 <br /> FN A-20 ;o Q/Df �f <br /> tp <br />