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APPLICATION FOR PERMIT <br /> - f <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> + 4 (209) 468--3447 <br /> i <br /> l R <br /> (Complete in Triplicate) <br /> Application is hereby made,to San.Joaquln County for a permit to construct and/or install the work herein described. This <br /> application is made in ccuplianceiwith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address_Owne <br /> r / fk1 __-- Address __�l� Phone <br /> - _._ _� . ._ M_,,. -.�,..�,. - - icense No. Phone <br /> Contractor �� ddress <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rDESTRUCTION ❑ Out of Service well C1 <br /> PUMP INSTALLATION C3 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAfiEST EP-TIC-TXNk " 'SE1%VWLINE5 DISPOSA FCD" """'�'�PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C) Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public I.1 Other J ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation Approxi Depth ❑ Eastern Surface Seal Installed by \ <br /> Repair Work Done 0 Type of Pump H,P. State Work Done _ <br />{ Well Destruction O Well Diameter Sealing Material 4 Depth <br /> t Depth rf Filler Material i Depth �1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ ,REPAIRIADDITION 0 DESTRUCTION septic system permitted.if public sewer is <br /> t ; available within 200 feet.) <br /> Installation will serve: Residence ommerciat Other <br /> l <br /> Number of living units: _ Number of bedrooms <br /> Character of wit to a depth of 3 feet.1 Water table depth <br /> SEPTIC TANK. ❑ Type/Mf® -CapacitNo-Compartments <br /> PKG. TREATMENT PLT. ❑ G� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line 1 <br /> SEEPAGE PITS 11 Depth ,I Size Number i. <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 it t <br /> l <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 /> I rules and regulations of the San Joaquin County <br /> 1 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." a f <br /> f e app rc t c I for I�rsuwed�W,.�- m drawing or! ►e a sid_a. Q <br /> Si Tr Ie: LlblzA 4&d4i2i Date: <br /> �1 <br /> FIO <br /> R DEPARTMENT USE ONLY <br /> W:� <br /> F Application Accepted bye Jt' _._ Date y Arae p <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> s <br /> Additional Comments: <br /> Applicant - Return all copies to:: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES u� <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BO% 2009, STOCKTON, CA 95201 <br /> . .-. _„. ' <br /> I AMOUNT DUET CASH <br /> AMOUNT REMtTTED ' CK INFO RECEIVED BY BATE PERMI7'NO. <br /> F <br /> i <br /> . EH 13.24 iREV.i i n 51 —1 C)0 ILA (30� Q/'a <br /> EH'4.26 t��.1 <br />