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_, . APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN COUNTYPUBLIC 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 compliance with Ban Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /� <br /> Job Address _ 0Q 06 ecr T � �"-*`K-f� <br /> City Lot Size/Acreage <br /> Owner's Name �E- Z�>"Address --- Phone <br /> Conlraclor ®� N ddress I License No. Phone r <br /> TYPE OF WELL/PUMP: NEW WELLe WELL REPLACEMENT _ DESTRUCTION CI Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR © OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL ! OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S f/( <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ZZ. Dia. of Well Casing <br /> Xbomestic/Private Gravel Pack 0 Tracy Type of Casing (! Specifications. <br /> R Public CCI/Other ❑ Delta Depth of Grout Seal Type of Grout:�/Z <br /> 0irrigation ;92 Approx. Depth CI Eastern Surf, a Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION D REPAIRIADDITION 0 DESTRUCTION 0 INo septic system permitted if 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 a 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: Wel Foundation PropertyLine <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS it Distance to nearest: Well -Foundation Property Line <br /> DISPOSAL PONDS 11 <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 ,Jl <br /> rules and regulations of the San Joaquin County a 1. 1 <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, Itshall not <br /> employ any person in such manner as to become subject to workman's cpmpensation laws of California." Contractor's hiring or sub-contractirig signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is iaaued, I shali employ persons subject to workman's Compania- <br /> tion laws of California." 'J <br /> The spplic mu req ions. Complete drawing onrq a/4V side, <br /> SignedTitle: `= Date: <br /> EPARTMENT USE NLY k' { <br /> Application Accepted by Date 4^ L�_tAiea <br /> Pit Gro Inspection by Date Final Inspection,by 5— Date <br /> Addi Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HALTH SERV IOIT <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES \ <br /> 445 N SAN,JOAQUIN, P O BOX 2009, STOCKTON, CA 88201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYE- DATE PERMIT NO. <br /> . EH13.7/IREV.1inb1 _ q_} CJ--9a - q0 <br /> EH'11.26 I 1 U <br />