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APPLICATION FOR PERMIT <br /> a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> *' ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> � RuI'r F.XATR>RR 1 YEAR kRQM DATH ISSUE_ <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 Public Health Services. <br /> !'r Job Address <br /> � z •� City n Lot Size/Acreage ;Z Af- V <br /> Qi1k z [ 3 <br /> Owner's Name C -� MAddress _, } _— Phone <br /> �Contrat Address r T% �icense No. �� Phoneme <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ! <br /> a <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack C] Tracy Type of Casing Specifications i <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> MI trrioation _ Approx. Depth 0 Eastern Surface Seal Installed by. <br /> Repair Work Done U Type of Pump H,P. '' State Work Done +W.& �— <br /> Well Destruction ❑ Well Diameter AIH Sealing Material &'Depth <br /> Depth -r -Filler Material,&,Depth <br /> IX) <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT ON J _ REPAIRlADDITION Ll DESTRUCTION G INo septic system rmitted i# public sewer is <br /> ., available wit 1861.1 <br /> installation will serve: Residence—. Commercia Other <br /> Number of living units Number of bedrooms <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg, Capacit No. Compartments <br /> PKG. TREATMENT PLT. Gl Method of Disposal <br /> Distance to,nearest: Well undation Property Line <br /> LEACHING LINE Cs No. & Length of lines Tota�ngtthtsizaFILTER BED n Distance to nearest: Welt Foundation Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 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 laws of California." <br /> The applicant must tail for 1 squired tnspection . Complete drawing on reverse side. <br /> Signed y Title- Date: f I b <br /> i R <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by �� ion <br /> DateAreaPit or Grout Inspection try Date nal Inspectby Date 1 <br /> Additlonal Comments: - <br /> Applicant - Return &U copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445:N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 98201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 9 J RECEIVED BY DATE PERMIT NO. <br /> INFO 0 <br /> �j CASH <br /> . EH 1314 MEV.1/0$51 �pOPQ--D 1/3796 <br /> EH,4.26 <br />