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APPLICATION FOR PERMIT <br /> $AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 5_5 <br /> ENVIRONMENTAL HEALTH DIVISION � <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <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 I <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 Health Services. <br /> Job Address � r — City s�6C �o(li_ Lot Size/Acreage _�� o X. I° d <br /> " Owner's Name SZAe � Address _ Z _ Phone <br /> I�•�Contraclar!tel r 7Y1 P � _—_Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 9 Out of Service well Ll � <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ _ 0TH ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHE LL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRC�BLIMVEA CONSTRUCTI ECIFICATIONS <br /> L1 Industrial a Open Bottom ❑ Manteca is, o I Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Peck ❑ Tracy ype acing Specifications <br /> * Public la Other ❑ Delta Depth of Gro eal Type of Grout �y <br /> Cd Irrigation Appro;. Depth stern Surface Said Installe <br /> Repair Work Done U Type of Pump H.P. Stat ork Done \ <br /> Well Destruction ❑ Well Diamet'l 1>0 <br /> to ial i Depth <br /> Depth IM Fill De <br /> � w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 "REPA JADOITIO ES.. t stem permitted if public sewer is <br /> 1 1',�` �# J� a i bl w hitt 200 feet.l <br /> installation will serve: Residence✓�I Commercial Q l t mcay r'ayt ' {, - <br /> Number of living units: Number of bedrooms f � - � a �thout <br /> Character of Boit to s depth of 3 feet:' t'` hrr !dr ter table deyth <br /> p t�i- P <br /> SEPTIC TANK. ❑ Type/Mfp �Cepati o. Compartments <br /> PKG. TREATMENT PLT, 0 ii '510 A,thod of Disposal <br /> Distance to nearest: Well Foundation Property Line + <br /> IM, 1 <br /> LEACHING LINE Cl No. & Length of linesTotal length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation l �" yProperty Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distanceto nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ IN <br /> I hereby csrtify 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 not- <br /> employ any portion in such manner as to�becoms subject to workman's compensation laws of Cahfomia." Contractor's airing 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 Cahfornle." I <br /> The applicant must call for all required i spections. Complete drawing on reverse side. <br /> Signed 7L_cJ�lrr ,a r�� '/ �o,✓ Title: — Date: (^ 7/ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by II Date �� Area <br /> Pit or Grout Inspection by I! Date Final Inspection by Date <br /> Additional Comments; IV.o �4 1 Z4 <br /> OM `� ~ Z40,& �` <br /> Applicant — Return all copies to* SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> �i <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> FEE <br /> INFO AMOUNT DUE �� AMOUNT REMiTTEO CASH CK 1 8ECEtVED BY DATE PERMIT"NO. <br /> .�} D Q C <br /> EN 13•24 IREV.tiM5i / -7 4 0 <br /> I� <br />