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ry APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Cie <br /> ENVIRONMENTAL HEALTH DIVISION <br /> C y P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-'3447 r ' <br /> YEAR VRQX DATE MUEDr <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construdt 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 San <br /> Joaquin County Public Health Services. <br /> r , <br /> Job Address ' 11 O City Lot Size/Acreage <br /> Address Phone <br /> Owner's Name ' <br /> Conlrac Addres ��� `�`}` License No ��Z Phon � <br /> TYPE OF WELLIPLIMP. _ _ NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well. ❑ l <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINEr <br /> _ FOUNDATION AGRICULTURE-WELL = OTHER-WELL5;-- --` PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CM Indus tel C1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omastic€Private ❑ Gravel Picky Z € .0 Tracy L Type of Casing Specifications <br /> M Public 1-1 Other ❑ Delta `Depth-of-Grout Seal Type of Grout <br /> M Irrigation _� .Approx. Depth ❑ Eastern Surface Seryl installed by <br /> Repair Work Done LEY Type of Pump '� H.P. ' - State Work Dane (� <br /> { Sealing Hateriil i DepthIlk <br /> Well Destruction D Well Diameter +. <br /> Depth f Filler ilDepth— <br /> k Depths <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION M. DESTRUCTION Cl fNo septic system permitted if public sewer is <br /> 1 w available within 200 feet.) <br /> Installation will serve Res+dence iCammerc+al x rOther �fi i � ` <br /> Number of IiVing units:.-' =Nuiitbe of bedrooms ` <br /> Character of soil to a depth of 3 feet: x Watar� g <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. C <br /> PKG. TREATMENT PLT, Cl � Methto u u Du r�pgss� � <br /> Distance to nearest: Well Foundation. Property Lin_ 1 <br /> ' 4 C+�1�i4 � <br /> LEACHING LINE C1 No. 8 Length of lines Total length/si EALTH <br /> FILTER BED ❑ Distance to nearest: Well Foundation ProTENTAL <br /> SEEPAGE PITS 11 Depth -Size y.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, se laws, an i <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-wti+cli,thif permit is issued, 1''shall n <br /> employ any person in such manner as to become subject to work mart's compensation-laws-of California," Contractor's hiring or subcontracting signatur <br /> certifies the following: "I canify that in the performance of the work for which this permit is issued, E shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus r all required_ inspections, omplete drawing on rse side. <br /> Signed X, Title Date: r L <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r ea <br /> PIS or Grout inspection by Date Final Inspection by r' Date <br /> Additional Comments: — <br /> h Applicant - Return all copies to: ISAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ,.,ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008,•3 ATOM, CA 98201 <br /> n <br /> FEE AMOUNT RUE AMOUNT REMITTED CASµ R I BY AT PERMIT NO. <br /> yINFO /� �,�} IV I I <br /> . EH 13.2/tREY.1 51 7 TSI APO �� r <br /> EH;426 <br />