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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)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 1 YEAR FROM DATE S <br /> (Complete in 'Triplicate) <br /> Application In 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 Public Health Services. <br /> Job Address uI City Lot Size/Acreage <br /> Owner's Name t Address f r �O Phone <br /> Contra. Addre� cense N — ; Piton l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well G7 <br /> PUMP INSTALLATION SYSTEM REPAIR 91-� OTHER ❑ Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> IN D USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustrial p Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> M Domestic/Privet* ❑ Gravel Pack' ❑ Tracy Type of Casing- Specifications <br /> i'1 Public Cl Other fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I I astern Surface Seal Installed by <br /> Repair Work Done of Pump H.P. 3-0_ State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-)-I--REPAIRIADDITIO.N t I DESTRUCTION I 1 (No septic system permitted if public sewer is C <br /> available within 200 feet.) <br /> Installation will serve: Residence _� Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of 504 to a depth of 3 feet: f ' t t <br /> tsrda <br /> SEPTIC TANK O Type/Mf r ; <br /> 9 Capacity r '� 0 LAn s <br /> PKG. TREATMENT PLT.0bFs� <br /> -_.. e_.,. <br /> Distance <br /> Distance to nearest: Well Foundation P <br /> ... �rtj" 2 7-1 3 <br /> LEACHING LINE C1 No.:8 Length of lines L Total IsSA I UAk2UII'4 L, <br /> FILTER BED 0 Distance to nearest: Well Foundation Vi51© <br /> SEEPAGE PITS,:;'`" 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation .Property Line <br /> DISPOSAL PONDS ❑- _ - --- — T- <br /> I hereby canify,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 licsnsed agent's signature certifies the following: 111 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 companss- <br /> tion laws of California." } <br /> The applicant must call far fquired in C6'nns mplete drawing on rev aside. <br /> Signed Title: 4 <br /> Date: <br /> - 'T-- OR DEPARTMENT USE ONLY f�, I <br /> Application Accepted by 4TDate �TArea �` <br /> Pit or Grout Inspection b ' J <br /> Y Date Final Inspection by Date r <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO RECEIVED BY DATE PERMIT'NO. t <br /> . EMIb24 InEV.i i R a) ,[ <br /> 4J r� L4?—? <br /> EH N.2! --tJ• 07) -3925 � � , !3 aJ1 <br />