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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENV IRONMENTAL. EALTH DIVISION <br /> P O BOX 2009, STC&Ibil, CA 95201 . `' <br /> (209) 468-3447 " <br /> YEA RATE 15SUER <br /> s (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 compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealth Services. 1 x l <br /> Cit ! � <br /> Ft r� 1 /rte ,1 w y ,fir_._wrr!97 Lot Site/Acreage I <br /> Job Address <br /> Owner's Name A.AA ddress <br /> L� h � <br /> License No.��Phone " '? <br /> Contractor 14._ � `� - _ .Address 16 6 <br /> TYPE OF WELL/PUMP: NEW WELL ID =WELL-REPLACEMENT ["1,..,a.-r DESTRUCTION,CI Out-of_Seryicerwell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REf'.AIR C7 OTHER ❑ Monitoring cell �� r <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private' ❑ Gravel Pack O Tracy Type of Casing Specifications <br /> r M Public Cl Other ❑ Delta Depth of Grout-Seal Type of Grout <br /> G Irrigation Approx. Depth ❑-Eastern . Surface-Seal-Ins tailed <br /> r Repair Work;Done L] Type of Pump k H.P. State Work Done _ <br /> Material i Depth f <br /> Well Destruction ❑ Well Diameter Sealing <br /> Depth Filler Material i Depth k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION fL DESTRUCTION G,Mo septic system permitted if public sewer is l <br /> available within 200 feeta <br /> s Installation will server Residence . Commercial Other <br /> Number of living units: Number of bedrooms x._ .. <br /> Character of soil to'a depth of 3 feat: Water table depth <br /> - � - <br /> SEPTIC TANK i❑ Type/Mfg t Capacity < . No. Compartments <br /> PKG. TREATMENT PLT. Cl ° Method of Disposal <br /> # Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Po.-& Length of cines To cal length/size- <br /> -'Line <br /> ength/size•--- <br /> FILTER BED .;; 0_.Distance to nearest: Well I - Foundation Property Line _.,. <br /> SEEPAGE PITS Depth �` Si:a Number r r <br /> SUMPS 11 Distance to nearest: Wall, Foundation_r _... Property Line <br /> I 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 Sen Joaquin County t ti <br /> certifies the following: "I cerflfy pnce ob <br /> Home owner or licensed agent's signature in the erformaf the work forkwhich{this permit is issued, I shall not <br /> employ any person in such manner as to become 4gtilect'lo workman s compensation laws of California,' Contractor's hinng or sub-contracting signature <br /> r certifies the following: "I certify that in the performance of the work fisc which this permit is issued, I shall ampfoy,persone subiect to workman's compensa- <br /> tion laws of California." / ' <br /> The applicant must call for all required inspections, Complete drawing on reverse side. <br /> Signed Title: r �Date: " <br /> i FOR DEPARTMENT USE ONLY I f <br /> ylicatlon Accepted byDate ` Area{or Grout Inspection by� Date Final Inspsction by Oate <br /> A� <br /> Additional Comments: <br /> »a� <br /> Applicant - Return all copies to: SAN JOAQ IN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH'DIVISION PERMIT/SERVICES ! <br /> Is <br /> 448 N SAN JOAQUIN#' P 0 BOX 2009, STOCKTON, CA-95201 <br /> FEE AMOUNT DUE t � � AMOUNT REMITTEDGASH - RECEIVED BY DATE PERtNIT'N0. r <br /> { INFO 1 ,r+� <br /> • FH 11-24 016V w!1 f �r C/C� ,v 064 9 . cd • <br /> I FH u•2s <br />