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APPLICATION FOR PERlI T ir•�' <br /> v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION JUN 6 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> (209) 468-3447 PFRMIVSERVICES <br /> YEAR PROM DATE I-qqfTym <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 cott>pliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> 97 Cit Lot Site/Acreage <br /> Jab Address <br /> �t f r <br /> Owner's Name <br /> _ Address 3 00- fur Phone r <br /> � .— <br /> Address TS`�a License No.�Phan <br /> Contractor <br /> TYPE_OF WELL/P41MP: NEW WELL © WELL REPLACEMENT f! DESTRUCTION Li of Service well 0 <br /> Monitoring well �� <br /> PUMP INSTALLATION � P----SYSTEM REPAIR P <br /> OTHER ❑ <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �—.DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL F OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> In Indu al ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (I Other -000118." Depth of Grout Seal Type of Grout <br /> 0 Irrigation � Approx..Depth- 0 Eastern--r ,Surface Seal Installed by <br /> Repair Work Done La_ Tyne of Pump�� H P State Work Done <br /> Well Destruction .t_© Waif Diameter <br /> Sealing Material i Depth <br /> at Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK.NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) " <br /> Installation will s04 Residence— Commercial_- Other <br /> S 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 Na. Compartments <br /> PKG. TREATMENT PLT. ❑ f, Method of Disposal <br /> r , <br /> Distance to nearest: Well Foundation Property Line <br /> L <br /> A LEACHING LINE ❑ No. & Length of lines a Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l l Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation; Property Line <br /> DISPOSAL PONDS PONDS ❑ <br /> E 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 /> I Home owner or licensed agent's signature certifies the following: "I cartify 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 subjeet to workman's compensation laws of California." Contractor's hiring of 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 /> FThe applicant ea t required i sactions, Complete drawing on r arse side. <br /> Signed Title: <br /> ` FOR DEPARTMENT USE ONLY 7 2 l <br /> Application Accepted by Date�• Area <br /> Pit or Grout Inspection by Date Final Inspection by Da'15_L!__ <br /> Additional Comments: ��`���►,(((��� <br /> Applicant - Return all copies to: ENVIJOAQUIN RONMENTALCOUNTY PUBLIC HEALTH SERVICES <br /> HEALTHDIVISIONPERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2000, STOCKTON, CA 95201 <br /> I FEE ' AMOUNT DUE AMOUNT REMITTED CASH AECEtVED BY DATE PERMIt NO. <br /> INFO <br /> . EH 13.24 IREV.t/R 5) ca -cl r 1'1 <br /> y EH 74.2a 4 <br />