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APPLICATION FOR PERMIT <br /> J3 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> Y 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 San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic a. r <br /> Job Address W City of Site/Acreage <br /> .t n <br /> Owner's Name 'c-J Address _ _ Phone <br /> Contract re ' <br /> •~�4�-- ice e Phone��I <br /> TYPE OF WELL/PUMP: Al NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION L1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR X-� OTHER O <br /> Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONI AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n End sl ❑ Open Bottom ❑ Manteca Dia, of Weil Excavation Dia. of Well Casing <br /> DomesticJPrivate C1 Gravel Pack C1 Tracy Type,of Casing <br /> Specifications <br /> II <br /> M public (1 Other ❑ Delta Depth of Grout Seal Type of Grout_ - <br /> CJ Irrigation /�'''Approx. Depth ❑ E stern (surface Seal Installed by <br /> Repair Work Done [8of Pump H. 1�/�� State Work Done <br /> � Type <br /> ISealing llfaterial k Depth (� <br /> Well Destruction ❑ Well Diameter � �� ��'A` <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION ❑ (No septic system permitted if public sower is <br /> available within 200 feet.) <br /> i. installation will serve: Residence..—. -Commercial'`.__Other <br /> Number of living units: Number of bedrooms ~.k <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. 0 '- \ \ Method of Disposal Z <br /> Distance to nearest: Well Foundation. Property Line PAYMENT <br /> El <br /> m <br /> LEACHING LINE C1 No'8 Length of lines Total length/size <br /> VED <br /> :. A�6-�-- '1892 <br /> k FILTER BED (1 r'Distance to nearest: Weil Faundation Property Line <br /> SAN JOA <br /> SEEPAGE PITS 11 Depth Size Number }_ f. _1ViCES <br /> SUMPS Ll Distance to nearest: Well Foundation P10peRVPM4nAr E LTH DIVISION <br /> DISPOSAL PONDS ❑ II <br /> I hereby comity 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 1 <br /> Home owner or Geensed 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 /> I 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 that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- <br /> tion laws of California." <br /> The applicant mus f all r`equir d i pections. Complete drawing on verse side. <br /> Signed x,_., _ _. Title: _ Date: <br /> VL=-FORDEIPARTMENT USE ONLY <br /> el <br /> Application Accepted by Date l A Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ?r <br /> ;I <br /> Additional Comments: <br /> n <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> F ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 SO2008, STOCKTON,,CA 85201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED'BY DATE PERMIT NO. <br /> INFO M <br /> a FH 13-24 IREV.1/$51Pic :.0.07 rJ(J 1,3C7/ 60 <br /> EH 71•Ie <br />