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-� APPLICATION FOR PERMIT <br /> SANT JOAQUIN COUNTY PUBLIC <br /> DIVISION TH VICES <br /> ENVIRONMENTAL HE _ <br /> 445NSBOXJ2009 <br /> IN, PHONE <br /> PO , STOCKTON, CA)95201420 <br /> PER11t T EXPIRES 1 YFR ilt D TE S <br /> (Complete in Triplicate) <br /> This <br /> Application is hereby me4e,to sea Joaquin County for s permit to construct and/or install the work herein described. <br /> of ban <br /> application is made in coopliance with San Joaquin County Ordinance No. 5w9 and 1862 and the Rules apd Regulations <br /> Joaquin County Public Health services. Lot Size/Acreage <br /> City <br /> Job Address I <br /> �+y U i Phone <br /> i Address ZJ <br /> I✓ Owner's Name Phone3 <br /> License No. <br /> �r (� Address DESTRUCTION ❑ Out of Service well <br /> NEW WELL ❑ ❑ <br /> „(Contractor WELL REPLACEMENT O OTHER ❑ Monitoring well C3 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES ___ � PITSISUMPS <br /> FOUNDATION .�—� AGRICULTURE WELL OTHER WELL^--^-- <br /> ��---- <br /> j INTENDED USE TYPE OF WELL PROBL�AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> 1 ❑ Open Bottom ❑ Manteca yV Dia. of Well Excavation Specifications \ <br /> * Industrial ❑ Tracy -Type-of Casing <br /> 4"1 Domestic/Private ❑ Gravel Pack Type of Grout <br /> I °� r! Dein �Depth of Grout Seal <br /> C1 Public e Cl Other <br /> � 5urface_SeniJnslalled by <br /> i I Irrigation Approx. Depth l I Eastern _ state Work Done— <br /> 'H:P. <br /> k Repair Work Done L3 Type of Pump _ Sealing Material i.Depth <br /> Well Destruction O r Well Diameter -- biller Material fi Depth 1`1 <br /> 1 Depth 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDlTION i I DESTflUCTtON INailabRe within 2t)a feet.) if public sewer is <br /> Installsl-O W11 serve: ' Residence— Commercial.� Other�-- <br /> ' Number of bedrooms�--- l <br /> � Number of living ur�ttsc. Water table depth <br /> Character of sap to a depth P t' CaPaci -— No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> w ,l <br /> PKG. TREATMENT PLT.❑ Foundation Property Line <br /> Distance to,nearest: Well <br /> `* Totallength/size <br /> LEACHING LINE CI No_6-Length of roperty Lina <br /> FILTER BED ;❑ Distance y rest: ,Well <br /> _—---- Foundation _ <br /> r <br /> Number ' <br /> SEEPAGE PITS Depth Size r <br /> Foundation -- Property Line <br /> SUMPS Cl Distance to nearest: Well t <br /> DiS11005 ONDS ❑ - -- <br /> 1 eby certify that l have Prepared this application end that the work III be done+n accordance with San Joaquin county ordinances, ata rvs. end <br /> cute*and regulations of the San Joacluin County g• , <br /> Home owner or licensed agent's signature certifies the following: I certify that in the performance r the work for which this permit is issued, !shall not <br /> that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa <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 <br /> tion laws of California." , <br /> The spplican s tali for all fired inspaUions. Complete°drawing on reverse side. ,f pate: <br /> �. Title: <br /> /Signedr <br /> R D DEPARTMENT USE ONLY <br /> J <br /> ► �"~' ..`�` ".,ti Date— �kAres Z <br /> Applic tion Accepted by l_J � Dat <br /> Date.. Final Inspection b <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> Applicant -Return all copies to: San Joaquin CoHeelth Permit/Servicesvices ti <br /> 445 N San-Joaquin, P O}Sox`2009,- 9tkn, QA'.,95201" <br /> r <br /> K RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> . EK 13-21 iREv.v M al t 00 <br /> Em 14.20 _ <br />