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APPLICATION FOR PERMIT ..i <br /> a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 (YEAR FROM 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 compliance with San Joaquin County Ordinance No. 549 and X862 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> /Services. <br /> Job Address I ^' �' w" --- - City Lot Size/Acreage 6 <br /> Owner's Name Phone�/Iddress �a-� Phone 3��- 9/0�iS <br /> Contractor I)�N r^�^oS C Address .-3-:53 /✓. �' nr Codi-/ cense No:s3_6"2—Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service Well O <br /> .,� PUMP INSTALLATION fry SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK /tJo SEWER LINES DISPOSAL FLD./5c` PROP. LINE,.150_'� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS _ <br /> .� INTENDED USE TYPfOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial pen Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing <br /> omestie/Private O Gravel Pack ❑ Tracy Type of Casing - Specifications <br /> M Public 1-1 Other O Delta Depth or Grout Seal _ �' r O�Type of Groua., Aa,- <br /> CJ <br /> a4❑ Irrigation / Approx. Oepth Eastern Surface Soul Installed b, <br /> Repair Work Done L_ Type of Pump, H.P. State Work Dona <br /> Well Destruction O Wall Diameter Sealing Material A Depth _`> <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION!] REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public Sower is <br /> available within 200 teet.l ; <br /> Installation will serve: Residence _ Commercial_ Other ' <br /> Number of living units: _ Number of bedrooms <br /> n <br /> Charutw of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> f <br /> Distance to nearest: Well Foundation Property Line �= <br /> n <br /> LEACHING LINE O No. g Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line !� <br /> SEEPAGE PITS 11 Depth Sirs Number <br /> .SUMPS LI Distance to nearest: Well Foundation Property Line . <br /> DISPOSAL PONDS O <br /> 1 hereby comity that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, Ono <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I comity 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 Calilornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's companza- <br /> tion law$of California." <br /> The applicant call squired inspections. Complete drawing on reverse title. <br /> Spned <br /> Title: <br /> Date: <br /> F fl DEPARTMENT USE ONLY q / <br /> Application Accepted by Date ^ 1 L Area QI 7 <br /> Pit rout 1 coon by -Date g - Final Inspection by��-��'k� Date? <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 0 BOX 2009, STOCKTON. CA 95201 <br /> FEE AMOUNT DUE AMOVNT REM1ITED CK RECENED By DATE PERMIT NO. <br /> NFO CASH _ <br /> EH 1374 IREV.11.01 (. n j ��, .,�'�� 11m � ? q 'I y �Q <br /> EH 142 �' ..� f ` q� 1 <br />