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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION E.S 1 <br /> P O BOX 2009, STOCKTON, CA 95201 tiDG <br /> (209) 468-3447 ta" <br /> R NO <br /> (Complete in Triplicate) `�U vv,N- <br /> Application is hereby mode,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is inside in cowilance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _57— City Lot Size/Acreage <br /> Owner's Name <br /> i11�54_ V/ L AiJZ>Q Address 5/JI',- Phone <br /> Contractor rLOZL j5 . Address Q-G­q - o4 4License No._, 7r�7b phone � S=3 `i7/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ - "`WELL-REPLACEMENT-C-_7 - DESTRUCTION ❑ out of ervice Well Moni ❑ <br /> toring Well <br /> PUMP INSTALLATION SYSTEM REPAIR L7 OTHER ❑ C7" <br /> DISTANCE TO NEAREST; SEPTIC TANK EWER LINES SPOSAL FLD. PROP. LINE <br /> FOUNDATION AG ULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL; PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> n industrial C3 Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> U DomesticlPrivate 0 Gravel Pack E7 Tracy Type asing Specifications <br /> ❑ Public Cl Other Q Del Depth of G t Seal Type of Grout r, <br /> Cl Irrigation Approx. Depth astern Surface Seal Ins ed by <br /> Repair Work Done U Type of Pump H.P. tate Work Done, � . <br /> Well Destruction O Well Diameter Sealing Material Depth <br /> rDepth Filler Notarial i h <br /> =�.. TYPE OF SEPTIC WORK: NEW 1N7Commorcial �ther <br /> ON 0 REPAIR/ADDITION LI D STR CTION (No tic system permitted if public sewer is <br /> avail is within 200 feet.) <br /> installation will serve: Residence --` <br /> �r <br /> Number of livog 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. Cl Method of Disposal Jl <br /> Distance to nearest: Well Foundation Property Line U / <br /> LEACHING LINE Cl No. & Length of lines Totat length/size <br /> FILTER BED 171 Distance to nearest: T Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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, an <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, 1 Shall not <br /> employ any person in such mannir as to become subject to wo(kman's compensation laws of California," Contractor's hiring or subcontracting 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 /> The applicant must call for all required inspsctions, omplete drawing oside <br /> n <br /> X:X <br /> Signed <br /> Title: Dater—g� <br /> e <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _jam) - - - Area <br /> Pit or Grout Inspection by _-' 'Date "'i Final Inspection bygo <br /> �, ,rr! <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 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERtNI7 N0. <br /> INyyF••��O CASH • <br /> . EN 13-21 rREV.t i n 51 y,J '`��•�0 7r) 00 361-1 �� � ' I 'Q 1 �1�'`� 1 I <br /> EH;42e _ I <br />