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r APPLICATION FOR PERMIT r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON; CA 95201 <br /> PERMIT EMIR ES 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 compliance with San Joaquin County Ord i ce No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I <br /> Job Address " Q T<�^ City grsca` t Size/Acreage <br /> ­tr <br /> OWner' ame AJt r Address n T <br /> r fiiPhone <br /> w Canitattor 'E+. <br /> AddressYI..�'�-����-Q License No. a� Phone a+' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST:,SEPTIC TANK----SEWER•LINES----- —DISPOSAL-FLD. -- -PROP. LINE.. <br /> I FOUNDATION AGRICULTURE WELL aOTHER WELL PITS/SUMPS <br /> INTENDED JSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia- of Well Excavation Dia.`of Welt Cw aV g <br /> fl Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications. I f <br /> 7 i <br /> ['1 Public I:1 Other (l Delta Depth of Grout Seal � Type a1 Grout'"" s <br /> I i Irrigation Approx. Depth I I Eastern Surface Soul Instaile8_by <br /> f Repair Work Done v Type of Pump H.P. State Work Done_ <br /> ' Sealing Material i thl I + <br /> Wall Destruction ❑ Well Diameter nB �P <br /> Depth filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION [ I DESTRUCTION I,J�..INo se'tic s'ysiem pe <br /> ip rmitted if"public sewer is <br /> aJailable-within 200 feet.) f �' <br /> Installation will serve: Residence X Commercial— Other - <br /> Number of living units: Number of bedrooms <br /> Character of soM to a depth of 3 feet: ~�B 01 A Water table depth / J <br /> SEPTIC TANK. ;` ❑ Type/Mfg Capacity No. Compartments _ ^_ <br /> s <br /> PKG. TREATMENT PLT.❑ _ _ _ Method of Qi l00 <br /> - f <br /> Distance to nearest: Well Foundation ! Pr4pBR� Line <br /> Y� <br /> LEACHING LINE f Cl No. 6 Length,ol.linea-• 9. Totpl length/size <br /> FILTER 13ED ❑ e Dist-ance to nearest Well _ Foundation Ilf Property Line Cop <br /> SEEPAGE PITS # ?- s Number <br /> € Depth Sire <br /> SUMPS l L:I Distance to rlearait: Walf 0 Foundation_LP Q 'Property` Line 2- q <br /> F DISPOSAL PONDS <br /> I hereby certify that I have prepared this-applicationand.that the-work will be done in sccordan6alwith San Joaquin county ordinances, Ante laws, end <br /> rules and regulations of the San Joaquin County r county <br /> tl t <br /> Home owner or licensed agent'a signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> r 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; "1 certify that in the performance of the work for which this permit is issued,1 shall.employ persons subiect to workman's compensa- <br /> tion laws of California." - - <br /> The applicant t call foLAII required inspectio :@C plate drawing on reverse side. <br /> 4 f <br /> Signed Title: -d!n v,.J_ I., Date: {� <br /> f <br /> OR,9EPARTMENT USE ONLY ` <br /> Application Accepted by Date �~/ res <br /> f <br /> Pit or Grout Inspection by Date Final Inspection by r�� Data / <br /> s <br /> E � ,err--�..•. ,,it:: ! <br /> Additions) Comments: _ <br /> Applicant!, - Return all copies to: San Joaquin County Public Health Services <br /> P Environmental Health Permit/Services I <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 � <br /> t � i <br /> CK <br /> FLEE <br /> NFObAMOUNT DUE AMOUNT REMITTEQ CASH RECEIVED BY DATE PERM17'NO. <br /> . EH 13-21 1 NEV.v/N 61 �� b / �¢ <br /> 'ell' Elf 1I-31 („�•� <br />