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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL allALTH M DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468—x ��3�f3D <br /> R PROM <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit io construct and/or install the work herein described. This <br /> application is made in coot>aliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules <br /> Joaquin Cpunty Public Health Services. and Regulations of San <br /> Job Address City, f, Q^ Lot Size/Acreage <br /> Owner's Name Address �__ � L� f -(�� phone <br /> Contractor <br /> Address License No. s <br /> l TYPE OF WELL/PUMP: NEW WELL ❑ �,Phone <br /> WELL REPLACEMENT [ } DESTRUCTION ❑ Out of ServiJWe <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitori <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDlSP05AL FLD. AROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYRE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONSfl Industrial ❑ Open Bottom O MantecaDia. of Well Excavation Dia. of Well Casing <br /> U DomesticlPrivate ❑ Gravel Pack L7 Tracy Type of Casing❑ Public i"1 Dther Specifications "�i11 <br /> l ❑ Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW 1NSTALL.ATION REPAIR/ADDITION 0 DESTRUCTION C1 availa(No septic system permitted if public sewer is <br /> \ <br /> Installation will serve: Residence� Commercial�„ Other ble within 200 feet.)_ <br /> Number of living units: --1-- Number of bedrooms <br /> Character of Solt to a depth of 3 feet: <br /> SEPTIC TANK. <br /> ❑ Type/Mfg # Water table depth <br /> b4 <br /> PKG. TREATMENT PLT, ❑ capacity No. Compartments <br /> .4 Method of Disposal <br /> Distance to nearest: WellO(; ` Foundation . <br /> Property Line <br /> LEACHING LINEUr ' <br /> No. & Length of lines "'" rd Total length/size V <br /> FILTER BED C'1 Distance to nearest. Well„ <br /> ...,.ndation operty Line <br /> SEEPAGE PITS I I Depth ------------- <br /> Size Number <br /> - SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑ Foundation�^_______ property Line <br /> I <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 cenifies the following: "I cortifY 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 Calif0fnia." Contractor's hiring or subcontracting 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.' I <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: C.r._! I-✓..2 Date: <br /> F DEP MEN SE O <br /> Application Accepted by 9 <br /> Pit or Grout Inspection by Data res, <br /> Dates Final Inspection by <br /> Additional Comments; <br /> Date <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 BQX 009, STOCKTON, CA 95201 <br /> kE <br /> IN 0 AMOUNT DUE ' AMOUNT REMITTED CK <br /> RECEIVE() BY DATE PERMIT NO. <br />. EH 1 .21 fREV. est m &I �E�-� <br /> EH 14•2e Y y11 <br />