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APPLICATION FOR PERMIT j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES = <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> (209) 468-3447 NOV 3 0 '1990 <br /> ZMIT EXPIRES ITYEAR I�ROId DATE ISSU WIRONMENAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVi'CES <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in made in coagiliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health <br /> Services. <br /> ' <br /> .. . <br /> Job Address City Lot Size/Acreage <br /> Owner's Name s Phone I <br /> � 5 5 j <br /> or _ZZALPhone�/ ZjA <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN C1 DESTRUCTION 0 Out of Service Well Cl <br /> PUMP INSTALLATIOh-JXr—> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._. <br /> INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS w - <br /> i.1 Industrial ❑ Open Bottom ,❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> /kr5;mostic/Private _f 1_GcaveE.Pack L7 Tracy Type of Casing specifications j <br /> M Public f-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation Approx, Dap h astern Surface Seal Installed by ock <br /> Repair Work Done Type of Pump H.P.I St e or o <br /> Weil Destruction O Well Diameter $�/ Sealing Material i Depth �•t <br /> Depth_ ZFZj:L Filler Itlaterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION!❑ REPAIR/ADDITION 0 DESTRUCTION CI lNo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence^ -Commercial Other <br /> Number of living units: Number of-bedrooms , <br /> Character of soil to-s depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> —1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county-ordinancas,-state laws,--and='- =� <br /> rules and regulations of the San Joaquin Oounty <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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shali employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The applicant must call or I1 required inspoctions. Complete drawing on roveog side, <br /> Signed Title: Dote: <br /> -- OR DEPARTMENT USE ONLY <br /> -Application Accepted-by T - Date f �� Area Z/ <br /> Pit or Grout Inspection by Date Final Inspection by �� ����,�n,,�_ Date 1 <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO.r-7 <br /> . EH 13-24 MEV,I I A 51 �� f <br />