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APPLICATION FOR PERMIT <br /> 11 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> li p O BOX 2009, STOCKTON, CA 95201 <br /> (249) 468-3447 <br /> y <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address <br /> � " Ciry <br /> Y \ Lot Size/Acreage <br /> �� � ' <br /> ._.. / <br /> Owner's Name @ I Address I c�t�/ 7 �i1 Gk fA� r ail 1 Phone <br /> _ <br /> / I <br /> Cpntractor f�r 1�h Address �- License N -� Phan <br /> TYPE OF WELL/PUMP _ _ NEW WELL C7 WELL REPLACEMENT C W�� <br /> STRUCTION Ll Out of Service Well ❑ <br /> 1 PUMP INSTALLATION , Monitoring Well <br /> SYSTEM REPAIR)i(" Tt E 'Cl ! <br /> DiS�7ANCTEnTO NEAREST: SEPTIC TAMC �&fte. ""'SEWER-LINES k DISPOSAL FLD. - PROP, LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> e <br /> ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial Open Bottom ❑ Manteca Oia. of Wall Excavation Dia. of Well Casing <br /> omesticlPrivate ❑ Gravel Pack 0 Tracy - L.Type of Casing Specifications <br /> �3 P blit ;" f:1 Other ❑ Delta Depth of Grout Seal .�. Type of Grout a <br /> ),Zil <br /> gation3c,[1.Approi. Depth 0 Eastern Surface Sidi Installed byr Work Done >9 Type of Pump :5,2,k_ H,P,,-7 S- - State Work Done We <br /> Well Destruction D Welt Diameter Depth <br /> Sealing Material S <br /> Filler Material i Depth <br /> 1 Depth <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION 0 AEPAIRIADDITION O DESTRUCTION CI.INo septic system permitted if public sewer is <br /> .( c available within 200 feet.] <br /> r. 1 Installation will serve: Residence .=" Commercial Other ; 44 <br /> WWWi F <br /> Number of living units: Number of bedrooms . <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity "` No, Compartments <br /> �j PKG. TREATMENT PLT. 0 ig Method of Disposal [ <br /> c./ Distance,to nearest: Well Foundation Property Line l <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED X-' n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i l Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS-:O-- <br /> I hereby comity 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 Sin Joaquin County <br /> Home owner or licensed agent's signature cenifies 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 taws of California," Contractor's hiring or sub-contreeting signature <br /> certifies the following: "I certify that in the performance of the work for which this,pe mitis issued, l shall employ persons subject to workman's componsa- <br /> tion laws of California." II <br /> The applicant mus tt, ui <br /> call <br /> �for all required inspections,-Complete drawing an rovers aid <br /> Signed`a ""7g2 {U/ w �I`l1 AAP¢ ,--- Title: Date: <br /> F PARTMENT USE ONLY <br /> �141Application Accepted by <br /> Oats Z� Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: -- <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> p ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> ' 445 N SAN JOAQUIN. P 0 BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUEAMOUNT REMITTED CK RECEIVED 8Y DATE "PERMJINFO7� CASN EM13.241REV.1ineiaV <br /> EN IZ-20 <br /> . —. <br />