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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9520 . <br /> 4 (209) 468-3447 <br /> YEAR VRQM DATE ISSUED <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 /> LConlractor.K <br /> n is toade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> tfnty 6P�ubQlic Health 3ervicee. ,pt J ��� City "FN' Lot Size/Acreagee JJ11_5 - Address 3P 5P�0 /4S�Qf� QoI Phone�t Address License No. Phone <br /> ELL/PUMP: NEW WELL❑° ' % 1 WELL REPLACEMENT ❑ . .tDESTRU_CTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER O Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK ': SEWER LINES DISPOSAL FLD. aPROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WE"-" PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C0NSTRUCTI0NR5PECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca_�--"_Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private �clGravel Pack rT acy.. Type of Casing Specifications (� ,❑ Public ❑ Delta Depth of Grout Seal Type of Grout "VCJ Irri0ation _.Aoprox. Depth ❑ Eastorn Surface Seal Installed by <br /> Re ' ork Done 0 Type of Pump H.A. State Work Done <br /> Welt Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> - I <br /> YPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION LI DESTRUCTION G (No-septic system permitted if public sewer is <br /> available within 200 Ieel.I <br /> Installation will serve: . ices deuce ".� Commercial_ Other$ '# <br /> Number of living units: � Number of bedroom r <br /> Character of soil to a depth of 3 feet: S v Water table depth <br /> SEPTIC TANK. IK Type/Mfg Capacity. /6 D 0No. Compartments <br /> PKG. TREATMENT PLT. Ll Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines „'- Total length/size <br /> FILTER,BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth4 -7, 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 t <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 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 /> he applicant must call for all required inspections. Complete drawing on reverse side, , <br /> Signed Title' <br /> Date:OF V <br /> F DEPARTMENT USE ONLY <br /> Application Adapted byDate k � __- Area <br /> Pit or Grout inspection by Data Final Inspection by _ Data z4zllL, <br /> Additional Comments, <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCXTON, CA 95201 <br /> IEEE AMOUNT DUE AMOUNT REMITTED CASH t RECEIVED BY DATE PEAMIT NO. <br /> EH 13 2i IREV.r i e s) <br /> Em,4.0 o� <br />