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r _ o <br /> APPLICATION. FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> -YoENVIRONMENTAL HEALTH DIVISION <br /> P O�BO% 2009, STOCKTON, CA 95201 <br /> (209) 468 __P_-0 <br /> PFaRIB T T EXPIRES DATE -W%= <br />! (Complete in Triplicate) 1; <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This 4 <br /> fapplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. t <br /> Job Address City c��dCLot Size/Acreage <br /> j <br /> f K �/�O/✓J tet/ �7y7 Address C�ZIr �.A/i9i1/® sf i✓ Phone <br /> Owner's Name ---� <br /> Contractor C&)61 t ;_y Address License No: Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> i DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> fINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1'1 Other O Delta Depth of Grout Seal Type of Grout <br /> G Irrigation _.Approx. Depth :�O Eastern ' Surface Seal Inst ailed by <br /> i! Repair Work Done U Type of Pump H.P, State Work Done_ <br /> I Well Destruction O Well Diameter �� Sealing Material Ir Depth <br /> Depth Filler Material i Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Or DESTRUCTION G (No septic system permitted if public sewer is <br /> i� available within 200 feet.) <br /> i <br /> Installation will serve: Residence_, Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC.TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest` Well Foundation, Property Line <br /> 1 t,.ai <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> 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 laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifiesithe 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 mubject to workman's compensation laws of California." Contractor's hiring or sub-cotracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." j <br /> The applicant mu all for all required ins ctiona. Complete drawing on reverse side. _ 4 <br /> Signed Title: 1,4 •- Date: <br />! R DEPARTMENT USE ONLY <br /> Application Accepted by Date��1 L Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SfiRVICE3 <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 Nl�SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEEINFO AMOUNT DUE K If <br /> O°UNT REMITTED CASH RECEIVED BY ry DATE PERMI7''�N,O. <br /> . EH 13•74 IREV.riwsr (�v,Q� i ryoty� /b � oC a�7^ l ( <br /> EH14-211- mac: f <br /> f <br />