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f <br /> APPLICATION WOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> fit,? r Q a (209) 468-3447 <br /> ERIiIT F FIRES 1 YEAR PROM 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 /> application is made in eoispliance 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 /> Q �— City Lot Size/Acreage <br /> Owner's Name .O Address _ G '""" _ Phone <br /> Contractor�� Address - 3F V6 0f_License No.3 Q � Phone <br /> 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ) DESTRUCTION C1 Out of Service Well Ll <br /> PUMP-INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications J <br /> VrPublic Ill Other 0 Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation Approx. Depth q Eastern Surface Sed! Installed by <br /> 11 <br /> Repair Work Done KType of Pump H.P. ? - State Work Dona <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> k Depth 3 ..Filler Material.& Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L3 DESTRUCTION D lNo septic system permitted if public sewer is <br /> #�. t .r available within 200 feet.) <br /> Installation will serve: Residence__,_. Commarclai : Other <br /> Number of living unite: Number of bedrooms <br /> Character of roil to a depth of 3 feet: Water table depth <br /> l <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, C1 Disposal <br /> i Method of Di oral <br /> E Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE El No. &.Length of lines Total length/size <br /> FILTER BED , n Distance to nearest: Well Foundation Property Line <br /> I SEEPAGE PITS 11 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 la 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 workman's compensation laws of California.','Contractor's hiring or sub-contracting signature <br /> certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's ompens <br /> tion taws of Calif <br /> t <br /> The app' nt must for all required i tions. am C drawing on rse side, �/ <br /> f SignedTitre: Date: T <br /> F0 >,PARTMENT USE ONLY <br /> Application Accepted by DateLit-X _ ._. Area <br /> a <br /> Pit or Grout Inspection by Date Final Inspection by Date 7T' <br /> f Additional Comments: 13 o f7C c ' 4 C4 K <br /> Applicant - Return all copies to) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES rte` <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> CK RECEIVED BY DATE PERMIT NO, <br /> INFO f� <br /> . EH 13'244REV.I/R51 E� �u � <br /> EH,4.20 1111 <br /> t <br />