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F x APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I P O BOX 2009, STOCKTON, CA 95201 <br /> 1 <br /> 1PERMIT EXPIRES 1 YEAR FROM DATE S <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 in made in cctepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatlone of San <br /> Joaquin County Public Health Services. <br /> �ob Address �Jt _ _ City tr Lot Size/Acreage ✓ <br /> rwner's Name,6,aa_7`f'Z_6 Address (� � Phone / <br /> �onlractor C �� LAddress1 <br /> � License Na <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ <br /> k' <br /> ! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (7.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Il Public l-1 Other � ll Delta Depth of Grout Seal Type of Grout V� <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE; OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION [ I DESTRUCTIO I fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_J Commercial— Other <br /> € Number of living units: Number of bedrooms <br /> Character of Will to a depth of 3 feet: - Water table depth <br /> SEPTIC TANK 0 Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ <br /> ti Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4l <br /> LEACHING LINE 0 No. far Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> tl <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br />° DISPOSAL PONDS ❑ I <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, 1 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 signsture <br /> certifies the following:"I unify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion lays of Calif fa.,, <br /> The applicant call for ahr uw ins tions. Complete drawing on rove side <br /> Title: ' Date: Z <br /> 7aFO DEPARTMENT USE ONLY <br /> Application Accepted by Date 9" Z Area_��_- „{ <br /> Pit of Grout Inspection by Date Final Inspection by Date (0- 1 <br /> Additional Comments: 1 <br /> -1 G 5 <br /> Applicant.- Return all copies t <br /> 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 /> FEE AMOUNT DUE 5I AMOUNT REMITTED <br /> LK RECEIVED BY DATE PERIrt17'NO. <br /> INFO CASH <br /> 1H 13,24 /` ice <br /> • EH ls•2e It1EV.f/s Si 'Ac <br /> -F�CO� Q� C.lw..Y`• / -a� �� 9d- 3 <br />� � L <br />