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} APPLICATION FOR PERMIT <br /> ` <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 /> F <br /> PERiIiT EXPIRES 1. Y R M )T9 U <br /> (Complete in Triplicate) <br /> Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. is <br /> application is made in compliance vith San Joaquin Court y <br /> Joaquin County Public health Services r 6?e,- ..� <br /> icy Lot 'ize/Acreage _ <br /> Job Address ZJ <br /> 26 U6 Phone <br /> Address ,✓ &Jf <br /> Owner's Name <br /> , 717 Phone <br /> ,Q r ' ddress License No. <br /> Contractor DESTAUCTIQN ❑ Out of Service well Q " <br /> WELL iiEPLACI ENT ❑ Monitoring well <br /> TYPE OF WELLlPUMP: NEW WELL ❑ SYSTEM R PAIR ❑ � OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> ISP <br /> SEWER LINES QSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _�— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONof ell EO ovaon SPECIFICATIONS Dia of Well Casing <br /> L, Industrial 0 Open Bottom ❑ Manteca Specifications <br /> Type o Casing <br /> C! Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> i"! Public la f <br /> Other l Delta _.Dept of-Grout Seal <br /> I I Irrigation —.Approx. Depth l I East n Surf ca Seal Installed by <br /> H P State Work-Done,._. <br /> i Repair Work Done U Type of Pump Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter Piller Material 0 Depth <br /> p Depth <br />? TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I l DESTRUCTION I I avaiiabNo leiw shin 24stem 0 feet{led d public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: ¢Number of bedrooms" Water table depth <br /> S Character of$oil to a depth"of 3 test: <br /> SEPTIC TANK D Typal Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. L7 —0 I, z Method of Dispose <br /> Distance to nearest: Well –/—Fadi itidation Property Line <br /> Totallengthlsiza 1 <br /> LEACHING LINE Cl No. g Length of lines �CL �-� <br /> FILTER BED ❑ Distance to nearest: WellC6 4�Foundsfiwn ZC) Property Lina <br /> SEEPAGE PITS 11 Depth <br /> Size N er <br /> r SUMPS C! Disunca.to rlsa Well oundation Property Line <br /> C <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, an "''-r%, <br /> rules and regulations of the San Joaquin County �) <br /> Homs owner or licensed agent's signature certifies the following: "! certify that in the performance of the work for which this permit is issued, I shall not <br /> " employ any person such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contrsctinq signature <br /> in <br /> certifies the personfollowiin 111 certify feet in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." _ <br /> The applicant must 11 for all r inspection Complete drawing on reverse side. � —� y <br /> / ! ISI l <br /> Signed % <br /> Title: Date: <br /> FO DEPARTMENT USE ONLY r <br /> f pate Area <br /> Application Accepted by /l <br /> Air Grout Inspection by <br /> te�, Final Inspection by Date <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 /> CK RECEIVED BY DATE <br /> EEE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> • EK 17.2 (REV.1 51 <br /> EN 14.20 <br />