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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQ <br /> UIN COUNTY <br /> ENVIRONMENTALPUBLIC HEALTHT <br /> VI d �S <br /> 445 N SAN JOAQUIN r PHONE1� 342 QP O BQ% 20U9, STOCKTON10--L--. T�_[,,, <br /> PERMIT EXPIRES YE R <br /> (Complete in Tripli all�,# �/ V q's- <br /> Application i■ hereby at deto San Joaquin County for a permit to construe and/or .a+Mib � is <br /> application is snide in compliance with San Joaquin County Ordinance No. 54 n <br /> Joaquin County Public Health Be ices. <br /> hen � <br /> Job Address ' No Cit 4ir Lot Size/Acreage <br /> 3�/ <br /> 16'' r 3 9 iq <br /> Owner's Name � Address ;I O �, Phone _ <br /> 5 r ,Q ,r� <br /> Cantrac Address . �� 2l/ 7 y� License No. 3 2Z Phone �v �Sra <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER ❑ l4onitoring 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 /> f7 Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Die, of Wall Casing _ <br /> L <br /> Fl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Cl Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout ._3 <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seat Insto4ad by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction 0 Wall Diamatw Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I PAI ADDITION DESTRUCTION I t {Na septic system parmittsd if public server is <br /> available within 200 lost-I <br /> Installation will serve: Residence� Commercial_ Other <br /> Number of living units: _1,,._ Number of s <br /> Character of soil to a depth of 3 feet: ,.r '�� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TAEATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � t f <br /> LEACHING LINE No. b Length of fines , - Total length/size X <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS >< Depth Sire Number_ f _ � <br /> SUMPS Ll Distance to nearest: Well!�a , Foundation Z19 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 sub-contracting signature <br /> certifies the following;"I certify that in the Warmance of the work for which this permit is issued, 1 shall employ parsons subject fo workman's compensa- <br /> tion laws of Coliforr"." <br /> The spoicsnt t call for P ui ad inspections. Complete drawing on reverse�sipa. <br /> Signed Title: 1 __ _ Date:�� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepred by Date Arsa� 2 <br /> Pit or Grout Impaction by Dats Final Inspection by Date RL1F <br /> Additbnol Comments: <br /> Applicant - Return all copies to; San Joaquin County Public Health Services <br /> Eavironmental Health Permit/Services <br /> 445 N San Joaquin, P d Box 2009, Stkn, CA 95201FEE /(// � ` <br /> Z ` INFO AMOUNT DUE AMOUNT REMITTED LASH RECEIVED BY DATE r `✓PERMIT'No.J <br /> r. E t�7„IrEtr. T' r ENH ii•� <br />