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6 <br /> 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 EBQX PATH ISSUED <br /> i (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County forma 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address -J L ��e. �_CrPctJ-' _ City Lot Size/Acreage <br /> Owner's Name ___ AddressPhone <br /> Contrao T -Addie License Phon"ZSS_ T" <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION �3� SYSTEM REPAIR C� OTHER O Monitoring Well t� <br /> DISTANCE TO-NEAREST7- SEPTIC TANK-----z----SEWER_.LINES,a- DISPOSAL_ FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n In�strisi C-) OpenBottom ❑ Manteca Dia, of Weil Excavation Dia. of Well Casing <br /> DDomeatic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Q Public 1-1 Other D Delta Depth of Grout Seal Type of Grout \ <br /> GI Irrigation �- Appro>t. Depth ❑ Eastern ,-Surface Seal Installed by <br /> Repair Work Done W. Typa of Pump H.P. State Work Done <br /> Well Destruction 1) Well Diameter. t Sealing Material 8 Depth <br /> Depth r Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ R€PAIWADDITION 0 DESTRUCTION Cl:(No septic system permitted if public sewer is <br /> . t available within 200 feet.) <br /> Installation will serve: Residence __ Commercial_ Other <br /> t ,- Number of living units: Number of,bedrooms <br /> Character of soil to a depth of 3 feet: ° ) - '""^ -- —Water tabie depth a <br /> SEPTIC TANK) 0--'.Type/Mfg " ' ' i i .Capacity-`_ _ No."-Compartments <br /> PKG. TREATMENT PLT. 0 � � � t '` Method of Disposal a <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance t) nearest; tr Well Foundation Property Line <br /> SEEPAGE PITS I I Depth F Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line T <br /> DISPOSAL-POND!�—O-_-,=- .. .,� �-•�,� �. -.�.. - �;. .,�..�..� _.• Y _ -. ..__. _ __ .. <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 signiiure cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:,'l-cinify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Iowa of California." <br /> The applicant must quired in�":Complete drawing on F9. se side. <br /> Signed Title: Date: . <br /> 3 <br /> OR DEPARTMENT USE ONLY I / <br /> Application Accepted by pato �' Cf2� P y�aY"•EN P`_J' o <br /> Pit or Grout Inspection by Date Final Inspection by y, r 2 `� <br /> Additional Comments: <br /> �F9 <br /> Applicant - Return all copies to: ISAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1. ri&'17 HEALTH SERVICES R <br /> {ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �N !ir'u4Nid(`NTAL HEALTH OIVISION <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 98201 <br /> FEE 9 <br /> INFO AMOUNT DUE �. AMOUNT REMITTED CK RECEIVED BY DAYE PERMIT N0. <br /> EN13-24 IREV,1/115) C/�� * <br /> EN 74•26 4L <br />