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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> G ENVIRONMENTAL HEALTH DIVISION <br /> i 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE I§SUEEI <br /> (Complete in Triplicate) <br /> - <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 Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public CH�ealth Services. <br /> + <br /> lob Address � r� / " v City jECcALD/V Lot Size/Acreageo <br /> �Q <br /> Owner's Name _�h7Fle/!i/�-' Address I a 7 C/T�t 7-- IC I�Q Phone <br /> ontraclor � LF Address License No. Phone <br /> TYPE OF WELL/PUMP: _ NEW WELL ❑ _ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well L� <br /> I� PUMP INSTALLA710N O SYSTEM REPAIR �iri ti OTHER ❑ Monitoring Yell C] <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES ISPOSAL FLD7 # PROP. LINE <br /> T" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing— <br /> Specification <br /> Il Public ill Other Cl Delta Depth of Grout Seal Type of Grout <br /> 1-1 Irrigation Approx. Depth I i Eastern Surface Seal Installed by 05 <br /> ,Repair,Work Hone 0 Type of Pump H.P. State Work Done, <br /> Well Destruction ❑ Well Diameter Sealing Material A Depth <br /> f Depth Filler Material i Depth -� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> I H I available within 200 feet.) <br /> Instillation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of moil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/MfgCapacity No. Compartments !? <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> ,. Distance to nearest; Well Foundit on_ Property Line <br /> LEACHING LINE Cl No. I} Length of lines �+ Torsi length/size �r.. <br /> l <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS IJ Depth Size Number Ilk- <br /> SUMPS'. <br /> SUMPS,. LI Distances to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ A <br /> r I hereby certify 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 . . - 41. <br /> Home owner or licensed agent's signature certifies the following: "i certify that in the perform_ance of the work for which this permit is issued. I shall not <br /> employ any person in such manner as to bacortlia subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature. <br /> certifies the following: "I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's eom nee•-_ <br /> tion laws of_Calefomfa. -. . . - --,• <br /> T applicantt a fo alt rT inspections.pec s. Com lete�drawin on reverse aids. - 14 - -- -- <br /> - ' Title: t <br /> Date: <br /> FOR DEPARTMENT USE ONLY b <br /> Applicatlon Accepted by Date v _ Z <br /> Area 19 <br /> Pit or Grout inspection by Date Final Inspection by Date- <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ` <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE�.' INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT N0. <br /> . EH 13-24 IFFY,„P,sr <br />'r fH <br /> 14•7e <br />