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1 <br /> APPLICATION FOR PERMIT FILE "OF <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEnurm MIRES 1 YEAR FROM DATE IaSUIM <br /> (Complete in Triplicate) <br /> Application is hereby Stade 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 axid Regulations of Ban <br /> Joaquin County,/�Public Health Services. C� qiy <br /> Job Address � �� r� r=—, +��� co 4d Lot Sise/Acreage <br /> Owner's Narnsl ^- -49"b Address /V, Phone <br /> Contractor Addes��T^�//rte �/ nae rt�+ '�' Phone <br /> r ' <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� <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 /> n Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout l� <br /> M Irrioation — Approx. Depth ❑ Eastern Surface Soul Installed by r� <br /> Repair Work Done 0 Type of Pump H.P State Work Done d <br /> Well Destruction D Well Diameter Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION C <br /> DESTRUCTION I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence.1& Commercial_ Other <br /> Number of living units: —�— Number of bedrooms i <br /> Character of aoN to a depth of 3 feet: �/ Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, C) Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1 No. b Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well ill C_�. Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance-to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O If <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, and <br /> rules and regulations of the San Joaquin county <br /> Home owner or licensed agent's signature certifies the following: "I 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 workmen'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 compensa• <br /> tion laws of California." <br /> The applicant must call for all required in ctio a. Complete awing on reverse side. ` <br /> Signed �% //__� a Title:l L:31t—� Date: <br /> T� F DEPARTMENT USE ONLY <br /> Application Accepted by <br /> �4, <br /> �,�� �^ Date Area <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additlonal 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 05201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I K 4 INFO CASH RECEIVED BY DATE PERMIT N0. <br /> CH 1324 IFIEV. Sr t c7--,z, ( 1 o p16�3 !v-lir CO. pd" co <br /> EH'4.2a <br />