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APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVE D I <br /> P O BOX 2009, STOCKTON, CA 95201 a C T 1 8 1990 <br /> (209) 468-3447 <br /> �E 'T EXPIRES 1,,,YEAR PROW-]DATE ISSUEDNVIRONMENTA! HEATH <br /> (Complete in Triplicate) PERMIT/SERVICES <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 Sart Joaquin County Ordinance No, 549 and 1662 and the Rules sAd Regulations of San <br /> Joaquin County Public Health Services, } <br /> Job Address A Orvg' �L,e IF ,.CJ Lot Site/Acreage <br /> wner's Name es Phone ` <br /> Con r wit icense No. >'hane <br /> ri <br /> TYPE OF WELL/PUMP: NEW WE l2%-1__1 WELL REFL—ACEMENt 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> I f 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 <br /> f-1 Industrial ! ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> _1"em stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Q Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> G lrr Dation1- -Approx. Depth ❑ Eastern rface Seul Installed by <br /> Repair Work Done 0; Type of Pump H.P.t,4 Stats Work Dana <br /> Weil Destruction 01 Well Diameter �� Sealing Material & Depth <br /> Depth Filler Material &'Depth <br /> TYPE OF SEPTIC WORK:TNEW:INSFALLATION 17.,,'REP_AklAAApOITJON_CI_DES-T..AUCT,IQh1 G (No septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will serve: ; Residence— Commercial Other ; <br /> F <br /> Number of living units: Number of bedrooms <br /> Character of soil to a bepth of 3 feat: Water table depth <br /> SEPTIC TANK. 1❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT:0 Method of Disposal � <br /> ' Distance to nearest: Well Foundation Property Line <br /> i <br /> ` R <br /> LEACHING LINE / :❑ No. $ Length of lines Tota) length/size <br /> FILTER BED <br /> f [Distance 1p a rest: Weil Foundation Properly Liffe. <br /> SEEPAGE PITS t i I Depth I Size Number <br /> SUMPS �. I LI Distance to nearest:{ Well Foundation Property Line C' <br /> _DISPOSAL PONDS <br /> 1 hereby certify that 1,68ve prepared this application and that the work wi$l be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regufstions of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "l certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person m such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> cariifies the foflowing 1 certify that in the performance of the work for which this permit is issued, 1 ahali employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant myq doll tI required inspections. Complete drawing on r arse side, <br /> l `. <br /> Signed Title: - Date: 6 i <br /> — _ <br /> FOIrDEPARTMENT USE O_ NLY / <br /> Application Accepted by' � p Area <br /> Vill <br /> Pit or Grout Inspection by Date Final inspection I �/�1 _ pate g <br /> Additional Comments: r <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERRIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMrTTED CASH K I RECEIVED BY DATE PERMIT'NO. <br /> EH 13.=a 5 L�7 <br />