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loflsifr3— WellS�rl�Sea`t�/ <br /> APPLICATION FOR PERMIT ,#pi-+ct!d aF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOC%TON, CA 95201 <br /> (209) 468-34kV <br /> REMIT URIB95 I YEAR k`RQL DATE ISSUED <br /> (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 coWliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of $an <br /> Joaquin County Public Health Services. <br /> Job Address --- - - _ City Lot Size/Acreage <br /> r Jam.- . • a� p �] <br /> Owner's Name _! y-r " '�^ / / L711— ddress -4 &'001 Phone <br /> Contract0, AddressZ%:5 Lice NPhone 9` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T� + <br /> 0 Industrial C;&44*n Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0140mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other 0 Delta Depth of Grout Seal Type of Grout <br /> CI Irrioation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material k Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L"f DESTRUCTION CJ iNo septic system permitted if public sewer is <br /> available within 200 feet.) Q <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of,bedrooms VI <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT,Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> m <br /> LEACHING LINE LI No. & Length of lines Total length/size p <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Propeny Line r� <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 cartifies the 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 subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following. "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- <br /> tion laws of California." i <br /> The appli an1 st call f all required inspections. Complete drawing on reverse side. <br /> Signed XTitle: - - Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> �___��'`q� [�� Area 13 <br /> Pit or Grout inspection by Date Final Inspection Dat e E t~�( <br /> i <br /> Additional Comments f <br /> Applicant Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON, CA 95201 <br /> kFEE AMOUNT DUE ;AMOUNT REWTTED I CASH RECEIVED BY DATE PERMIT NO. / <br /> . Ek 131RfV.f i n s� `� a-9 7 G <br />