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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH -SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 Y FROM DATE <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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Jriaquia County Public Health Services. <br /> tG City C& Al Lot Size/Acreage �n 4 <br /> Job Address <br /> Owner's Name L J Address Phone <br /> Contractor Address &EAVMfLicense No `'�Phone <br /> TYPE Of WELL/PUMP: N WELL ❑ WELL REPLACEMENT X DESTRUCTION L1 Out of Service Well ❑ <br /> PUMP INSTALLATION 13 SYSTEM REPAIR ❑ OTHER 0 <br /> ldanitoring Well ❑ <br /> 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F I-) Industrial Open Bottom ' ❑ Manteca Ola. of Well Excavation Dia. of Well Casing- <br /> @j(Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'1 Public F1 Other n Delta Depth of Grout Seat Type of Grout , <br /> I I irrigation _Approx. Depth I ].Eastern Surface.Sea1 Installed by <br /> Repair Work Done Ll Type of Pump H.P. _„2 1­ State Work Done �Pt"8' <br /> Well Destruction ❑ Well Diameter <br /> '.. Sealing Material i Depth <br /> R Depth biller Material i Depth <br /> TYPE: OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (Nail septic+ithin system permitted it public sower is <br /> Instaltation will serve: Residence—."Commercial Other <br /> Number of living units: Number of bedrooms` <br /> Character of soil to a depth of 9 feet: € ! Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg = ° Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: "Well Foundation Property Line = �' <br /> F <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I•I—Depth``" Size"—"' r """` ;"'"" -Number <br /> r SUMPS Lt Distance to nearest: Well R ;'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..stets laws, and <br /> rules and regufations of the Sen 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[Wanner 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 /> I The applicant must call for all required inspections. Complete drawing on reverse side. <br /> i <br /> Sigma X AO. Title: Date: _C—X,4/g.? <br /> FOR NT.USE ONLY <br /> Application Accepted by <br /> Dots Area • <br /> J <br /> tal r Inspection by Date Final Inspection by Datat"i Comments: / f <br /> Applicant - Return all copies to: San Joaquin County Public ealth Services Lin �2z o` t <br /> Environmental Health Permit/Services 0 g <br /> I, 445 N Baa Joaquin, P O Box 2009, Stkn, CA 95201 � �� -- <br /> F ffENT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EM M24IREV.I/HsY � � �3- <br /> EH 14-M <br />