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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 I <br /> (209) 468-X44-?314 ' <br /> Yrs t PROM DAM-LOM <br /> (Complete in Triplicate) i <br /> Application is hereby made to San Joaquia County for a permit to construct and/or install the cork 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 Health Services. <br /> i <br /> GY<F- Lot Size/Acreagea� <br /> Job Address � _fCity 1 <br /> 1�Ct!�tAddress LO_b pl y-r�AfAEr rte' �_ --- Phone <br /> Owner's Name Uu�noT3i�tpGE- <br /> Contiactor Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service We-11 ❑ <br /> OTHER Monitoring,well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ y,� A' tw <br /> t e <br /> SEWER LINES DISPOSAL FLD, PROP. LINE ' <br /> DISTANCE TO NEAREST:•SEPTIC 7A'NK '` i <br /> FOUNDATION AGRICULTU_ RE WELL OTHER WELL PITS/SUMPS �--1k J <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ill <br /> Ll Industrial Open Bottom ❑ Manteca'` Die. of Well Excavation Dia, of Well Casing <br /> Domestic/Private 0-Gravel L7 Tracy Type of Casing Specifications <br /> --- - °"" Type of Grout <br /> C Public i l Delta Depth of Grout Seal <br /> 0 Irhoation rorr, epth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material 4 Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 13 'REPAIR/ADDITION 0 DESTRUCTION 0 1 N septic system permitted if public sewer is 6u U&1 <br /> available within 200 feet.) <br /> Installation will serve: Residence — Commercial Other <br /> Number of living units: Number`of bedrooms <br /> Water cable depth <br /> Character of soil to a depth of 3 teat: <br /> SEPTIC TANK ❑ Type/Mfg' ° Capacity No. Compartments NIS) <br /> PKG. TREATMENT PLT.0Method of Disposal <br /> Distance to nearest: We(F Foundation Property Lina '9 <br /> Total len th/sized F <br /> LEACHING LINE CI No. & Length of lines g _ <br /> FILTER BED G Distance to nearest: Well -_„Foundation Property Lined <br /> SEEPAGE PITS I I Depth Size f A Number <br /> SUMPS LI Distance to-nearest: ,Well Foundaivon Property Line / <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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 Sen Joaquin County a <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 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; "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 must call Iv all required inspections. Complete drawing on reverse side. <br /> :Cti G�t� Date: y �� l <br /> Signed Titl <br /> FOR DEPARTMENT USE ONLY ��- <br /> # - -- Date. f1� _U _ Area_.�.3 -- <br /> Appficstiorti Accepted by (� 1; <br /> }n- �f` " <br /> Pit or <br /> Or o_ut..lnspaction by Data Final Inspection by Y Data f <br /> Additional Comments: <br /> A <br /> Applicant .-f Re turn all copies to: SAN JOAQUIN COUNTY PUEtLIC HEALTH 9t'sRVIC6S <br /> + ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES y� <br /> t 446 N SAN JOAQUIN, P O SOX 2008, STOCKTON, CA 85201 <br /> FEE RUNT DUs AMOVN7 REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> 'r INFO <br /> . EM 13.24IREV.iin614N�rflI . ,•�•� C1 <br /> EH t�•26 <br /> f <br /> 3 f � <br />