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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)488-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 1 <br /> PERMIT EXPIRES I YEAR FROM D T _SSUED <br /> (Complete in Triplicate) <br /> Application is hereby ­J_.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sun <br /> Joaquin County Public Heaallth Services. <br /> Job Address +� - G � City w Lot Size/Acreage <br /> i <br /> Owner's•Name _ IU Address "Phone <br /> Contractor �� � Address License Norte Phone 750 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM.REPAIR 17 OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC''TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNATIO.N AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE _TYPE'C7fLL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public - M l l Other fl Delta Depth of Grout Seal Type of Grout ` <br /> I I Irrigation" Approx. Depth I I Eastern Surface Seal Installed by v ] <br /> Repair Work.Done U' Type of Pump H.P. i State Work Done <br /> Well Destruction _ 0 Well Diameter Sealing Material i Depth - <br /> Depth Filler Naterial i Depth - <br /> TYPE OF SEPTIC-.WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will some: Residence Commercial_ . Other <br /> Number of living units: t Number of bedrooms <br /> Charactai of aoll to a depth of 3 feet: " Walter table-deptht"l <br /> SEPTIC TANK. ❑ Type/Mfg ..T_ Capacity A- No. Compartments <br /> PKG. TREATMENT PLT-.-D 'j r 7— Method of Disposal <br /> l <br /> 'Distance to nearest: Well Foundation Property Line <br /> LEACHING'LINE ;�L).� No. & Length of lines �U Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation D Property Line <br /> SEEPAGE PITSF. 1 1 `Depthr"` Size Number <br /> SUMPS pr" f.� Distance to nearest: Well O6� r Foundation do Property Line <br /> DISPOSAC PONDS �❑ <br /> I hereby certify that I have prepared ihis 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 env person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature _ <br /> certifies the following:"I certify that in the perlormance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mustcall f ail nquiraaJdd incpactions. Complete drawing on reverse side. <br /> Signed X_ Title: � <`' - Date: <br /> A DEP TME USE_ONLY , <br /> Application Accepted by Date rea � <br /> Pit or Grout Inspection by Date Final.),nopection by Dats#� <br /> Additional.Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> f 445 R San Joaquin, P O Box,2009,''Stkn, CA 95201 <br /> - INFOFEE-- AMOUNT'DUE AMOUNT REMITTED RECEIVED ii DATE *PERMIT"NO. <br /> . EN 1126 IAEV.vin 61 //7' 4P AS <br /> ��/ �C� `�✓ U / <br /> EK 11.70 <br />