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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES 1 YE FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 4 <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> I application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San <br /> Joaquin County Publics Health Services. 1� <br /> Job Address 5Zr°� City �*C Lot Size/Acreage <br /> S1��� Address su.� �° — Phone <br /> Owner's Name ,�� 11 cl <br /> Contractor Address � !0 License No. / - Phone <br /> r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO t of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> P DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public El Other Fl Delta Depth of-Groui-Seal Type of Grout � ) <br /> t I Irrigation —.Approx. Depth I I Eastern Surface Seat/ Installed by h <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth biller Material A Depth [ n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 foot.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sob to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg -" Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well "3 Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total lengthtsize <br /> FILTER BED ❑ Distance to nearest: Wen Foundation Property Lina /} <br /> t SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 <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 workmen's compensation laws of California." Contractor's hiring or subcontracting signsture <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 larva of Calif fa." <br /> The applican t call fQr jad r red ' a coon ( Complete drawing on reverse side. <br /> Signed Title: Data:- ..— Date: <br /> 9 Z_ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -�^^ 4 Date Z AreaDZ <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments:Comments: <br /> �;� ZN - <br /> Applicant - Return all copie to San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box-2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By OATE PERMIT•NO. <br /> INFO <br /> . EH s3•?4 tltEv.Fitisi r r tTJ UQ<--t 1/0 <br /> a g 2 RL- <br /> EN ti•Ia <br />