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` APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> t P O BOX 2009, STOCKTON, CA 95201 ZO--JC) L bV991 <br /> (209) 468-3447 f "171 VN~f� 60112 <br /> i 1?Rt4l1IT EXPIRES 1 YEAR PRQX DATE-I_SUM PEMMERVECES <br /> 1 (Complete in Triplicate) <br /> r 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 vith San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> 1 Joaquin County Public Health Services — q J <br /> /�Oi i��STi IP-Ly DF AV� �� �• OIF 9�ize/Acreage <br /> Job Address p,�� <br /> I c ��6/a6EZ !! [.�? 9fa 50r 49" t S Phone <br /> 0 //War's Name rase <br /> Oontractorsi!'�� �n e4dress g License No. 8 Phone �g— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, Mtnnitarina 4fe11 �y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, °per----- ] T <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS77G <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation !� <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4fteeirlie~5 <br /> M Public I.1 Other ❑ Delta Depth of Grout Seal 7gpe^offrent � <br /> ' C3 Irrigation w Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done pL.la6 rr Ili fje7 <br /> Well Destruction ❑ Well Diameter Sealing Material 6 Depth , <br /> Depth Filler Material ie Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION 7-1 (No septic system permitted if public sewer is <br /> Installation will serve, Residence— Commercial— Other available within 100 leei.l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> F SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments n <br /> PKG. TREATMENT PLT. ❑ Method of Disposal r <br /> Distance to nearest: Well Foundation Property Line le <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> + FILTER BED 1-1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby canify 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 <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 notro <br /> employ any person in such manner as to become subject to workman'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 t call for all red 'inspections. Complete drawing on reverse side. <br /> Signed X Title: MS6, _ _ Date: <br /> F <br /> FO D=TMENTUSEONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by &adDate 7 <br /> Additional Comments: 6111 <br /> s C G <br /> Applicant ^ Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES WAry <br /> J <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES ruorte <br /> 945 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 �" ! <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMI-r NO. <br /> INFO 0'0— CASH <br /> EH <br />