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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERI[IT ESPIRES 1 Y33AR ?ROM DATE IS§UED <br /> ,j (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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servics. <br /> Job Addraas <br /> Li 1�^� f'e[ City J` Lot Size/Acreage <br /> 1Nn}� f <br /> Owner's Nams �` hone��" � <br /> it _ L <br /> Contra Addre s S.- `] 'License N Phoran <br /> TYPE OF WE NEW WELL ❑ WELL REPLACEMENT ❑_ / DESTRUCTION ❑ Out of service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Y� OTHER © Monitoring Well E, <br /> DISTANCE TO NEAREST: SEPTIC TANK• � SEWER LINES DISPOSAL FLD. PROP. LINE <br /> -_ <br /> FOUNDATION' � GRICULTIfRE WELL----- ��- -•OTHER WELL PITS/SUMPS <br /> I t:nIDE0 USE _TYPE OF WELL PROBLEM AREA :CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fJ Do4►dstic/Private 0 Gravel Pack;, ❑ Tracy Type of Casing Specifications <br /> rlblic !-1 Other © Delta Depth of Grout Seal Type of Grout <br /> CI IrrigationApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done• L9' Type of Pump, � H,P. State Work Done <br /> Well Destruction ❑ Well Diameter'. Sealing Material i Depth <br /> Depth f hiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 0 DESTRUCTION CI.(No septic system permitted if public sewer is <br /> .available within 200 feet.) Q � <br /> Installation will serve: -Residence ,.,r`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. 0 Method of Disposal � 1 <br /> t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well{`` Foundation Property Line <br /> ,I _t <br /> SEEPAGE PITS I I Depth �. - n •Size. Number <br /> SUMPS Lf Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ s <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 ragulationa of the San Joaquin'County I <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: "I certify-thahin-the perlormance of the-work-forwhich-this permit-is issued,I-shall employ persons subject to workman's compensa. <br /> tion laws of California." ; <br /> The applicant of all required icoons. Complete drawing on averse side. Q <br /> Signed Title: Date: Z 0 � _ <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �VArea ICJ <br /> Pit or Grout Inspection by Date Final Inspection by Date-?,/224 a2_ tf <br /> ' a• i <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 0 Elpa 2009, STOCKTON, CA 95201 <br /> IFEE NFO AMOUNT DUE I AMOUNT REMITTED E CK RECEIVED BY DATE PERMIT N0. <br /> . EH 11-24(REV.11631 7� a• (JL �"C� �� T Z �LIZSQ� <br /> EH A.x <br /> 1 <br />