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I <br /> i APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL I <br /> NVIRONMENTALI +HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> Q P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <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 cceillance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyPublic Health Services. <br /> �CI Ca1 /1/ CQIt-hip f�N1-CJob Address City t Size/Acreage <br /> Owner's Namur/". ��_s1�6]/I ddress 4f00 '"call ldir►9LCIL Phone <br /> E I . <br /> Contractor C.t Address -pQ Ado 14?2I? : ''License No.�2 3 Phone <br /> TYPE OF WELL/PUMP: _ _ _NEW WELL.0 _ WELL.REPLACEMENT 11 DESTRUCTION_❑ Out of Service Yell C1 <br /> 4PUMP INSTALLATION ❑ SYSTEM REPAIR ,Q" BOTHER p monitor Ing Yell n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION_ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WILL' PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑.Open Bottom p..Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Crl 0 mic/Private -1316'ravel Pack • ❑ Tracy Type of Casing_ Specifications <br /> FT Public' Cl Other 'f Fl Delta Dept#i of Grout Seal Type of Grout <br /> i I I Irrigation _Approx. Dt!Bilrh Jr I.Esslern Surface Seal Installed by <br /> Repair Work Done 9?'/Type of Pump r r H.P' State Work Done 2raft rI <br /> WeM peatructgn ❑ Well Diameter Sealing Material & Depth <br /> 'Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK;, NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i lNo septic system permitted if public'sewer is <br /> available wiihin 200 feet.) 3 <br /> Installation will serve: Residence e Commercial _ Other <br /> `Y �► I ' <br /> Number of living unit:: Number ofrooms <br /> Character of soN to a depth of 3 feet: 'Water table depth Q <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKGf TREATMENT PLT. 0 _ t Method of Disposal <br /> Distance to nearest: Wel Foundation-,` -.Property Line <br /> LEACHING LINE ❑ No. E Length of lines Total lengthlsize <br /> FILTER BED C) Distance to nearest: W Foundation Property Line r,, <br /> SEEPAGE PITS t i Depth Size Number <br /> SUMPS LI Distance to neares Well �` Fou ion Property Line 1 <br /> DISPOSAL PONDS.` (:1S <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, a"to' laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licen nt's nature certifies the following:g; "I certify that im the performance of the work for which this permit is issued, I shall not <br /> employ any per In such ma r as to become subject to w rkman's compensation taws of California." Contractor's hiring or sub-contracting signature <br />{ certifies the fo wing: "I certify th t in the pert once o ork for which this permit is issued,I shall employ persons subject to workmin's compensa- <br /> tion loves of slifornla. I, <br /> The applies t r must c f requi, om a awing o Sid <br /> : <br />{ Signed Title: Dater47 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by —t 1 l— �L W ... T Dote v 7 Area 2 r i <br /> Pit or Grout Inspection by Date Final Inspection by Date: <br /> Additional Commantsw. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health,Permit/Services <br /> 445 R San Joaquin, P'O-Box 2009, ! tkn, CA 95201 i <br /> INFO EE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO.,i; <br />' + EH 13-24 IRt:Y,I i RSI 00 Q p <br /> EH i4•2a <br />