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6 <br /> ,APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> R <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 cotWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. 1 �n <br /> 3 1 f) S ity �!'�/`- Lot Size/Acreage 7L — <br /> Job Address <br /> .,Owner's Name S 1( Address Phone _ <br /> 'Contractor &I L Address _ /1WT License No. .22r-,CUPhone r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> ' <br /> PUMPi INSTALLATION C1SYSTEM REPAIR ❑ OTHER 13 "" ':MoniWring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. �' PROP. LINE <br /> FOUNOATION AGRICULTURE WELL OTHER WELL PITSISU.MPS• , <br /> INTENDED USE { i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R ` <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of.Well Casing — 0 <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing SpecificiiY+ons ' <br /> T� Public ("I Other ❑ Delta Depth of Grout Seal Type of?Grout <br /> Irrigation —Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. I State Work Done_ <br /> Weil Destruction ❑ Well Diameter Sealing Material i Depth- <br /> Depth Filler Material i DWh— <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 0 DESTRUCTION MilNo-septic system permitted if public`sewar is <br /> i available within 200 feet.) <br /> Installation wile serve: Residence Commercial_ Other ? <br /> I <br /> Number of living unit: Number of bedrooms <br /> Character of $oil to a dept of 3-fe0i: r �+� -`�._ N�ater•,table depth's <br /> SEPTIC TANK type/Mip Capacity. 1(400- IN -Comportments <br /> PKGI TREATMENT PLT. 0 f Method of Disposv <br /> Distance to nearest: Well# (rG Foundation T Property Line <br /> LEACHING LINE 9--NO. b Length of lines � Total lengthlsi:a <br /> FILTER BED,' n Distance to nearest: Well �' Foundation Property Line <br /> SEEPAGE PITS V'15;pth Size 4 Numbei <br /> SUMPS LI Distance to nearest: Well F Foundation Property Line <br /> DISPOSAL.PONDS ❑ a --- <br /> I hereby canify that I have prepared this application and that the worts` will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whicty 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 of 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 compensa• <br /> tion laws of California." <br /> The appficant must call for all equired inspgctions. Complete drawing on reverse side, <br /> Signed X Title: • Date: <br /> Y - FOR DEPARTM ' USE ONLY <br /> w Application Accepted by Date. F�°' S Area / <br /> Pit or Grout Inspection by Date Final Inspection by 1 Dots & <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CAK RECEIVED BY DATE APERMIT'NfrO. <br /> . EH 13,24 MEV.I/A 5) <br /> EH?{•2e f <br />