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y <br /> ,i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PEMIT EXPIRES 1 YEAR PRAM DATE :ISSUED <br /> (Complete in Triplicate) <br /> Application In hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules aad Regulations of San <br /> Joaquin County Public Health Services. <br /> o <br /> Job Address x- _ r City a Lot Size/Acreage <br /> Owner's Name �� � �� � � Address h Phone <br /> + Contractor <br /> �T Addresez// <br /> g i <br />.,_TYPE OF WELLIPUMP: *¢ NEW WELL ❑ WELL REPLACEMENT ❑� DESTRUCTION L7 Out of Service Well ❑ <br /> PUMP"INSTALLATION ❑ I SYSTEM REPAIR '01 OTHER El Monitoring well <br /> f 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 SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca t Dis, of Well Excavation Dia. of Well Casing i <br /> U Domestic/P(ivate ❑ Gravel Pack- C1 Tracy + Type of Casing _,Specificationt <br /> IPubtic C1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Imoalion Approx. Depth d Eastern Surface Soul Installed by <br /> -Repair Work Done 0 Type of Pump r H.P. State Work Done _ I <br /> Well Destruction O Well Diameter Sealing;Material i Depth <br /> Depth Filler Material & Depth ' <br /> {" TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR IAODITION DESTRUCTION G iNo septic system permitted if public sewer is <br /> _ f available within 200 feeLl <br /> ^ Installation+will serve:• Residence Commercial^ Other <br /> Num <br /> F <br /> Charac eoofvsoil to a dept 3 feet.ber of bedro Water table depth <br /> SEPTIC TANK.AWjV5110 Type/Mfg $ Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1- Method of Disposal `. <br />.I r Distance to nearest: Well Foundation Property-Line <br /> LEACHING LINE )9- No. & Length of lines 9=1-�z` �,f'`_____ Total length/size - <br /> FILTER BED f 1 Distance to nearest: Well Foundation-�G.� Property Line " <br /> SEEPAGE PITS Depth Size - r Number <br /> SUMPS Ll Distance to nearest: Well � Foundation property Lina <br /> DISPOSAL PONDS ❑ <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` l <br /> rules and regulations of the San Joaquin County <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 /> 4 certifies the fotlowing: I certify that in the perlofmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• j <br /> tion laws of California." <br /> i <br /> The applicant must call fof all required ins pe do s. Cgmplete rawing onre eY rse side. <br /> Signed/ / Tide`c- Date: " <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date , y Area <br /> c r r /} <br /> P or Grout Inspection by/t' ate �Final Inspection b <br /> ats <br /> dditional Comments: <br /> Applicant - Retum ali'copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> I # 445 N SAN JOAQUIN, P O BOR 2009, STOCKTON, CA 95201 <br /> EE <br /> INFO AMOUNT DUE AMOUNT flEMtTTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 13-24 IREY.riM K 7 . 00 <br /> ' EH 14-M <br /> \­�:,/* <br />