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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMIIdTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, ,PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, 'CA 95201 <br /> PERMIT_E%PIRES 1 YE_ FROm DATE -ISSUED <br /> .(Complete in Triplicate) <br /> Application 1s hereby made to Sd'a Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquip County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Pub�c it th <br /> Job Address �lo7,� City Lot Size/Acreage <br /> Owner's Name .L �► 4 — -- Address T, U: �f3 �x 714!`6CCA2 Phone Ze <br /> L , L95`3 <br /> Contractor �hS Address R&L016a d _6 IIULicenseNo.32! d3_2_ Phone Z-S j�' <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well Cl <br /> PUMP INSTALLATION Q : SYSTEM REPAIR 0 OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, . PROP. LINE <br /> FOUNDATION" AGRICULTURE WELL OTHER WELL `'*- ""PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom © Manteca, Dia. of Well Excavation Dia. of Well Casing <br /> C] Domestic/Private Gravel Pack 06 Tracy Type of Casing Specifications <br /> 11 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx'. Depth l I Eastern Surface Seal Installed by <br /> r A � �1 <br /> ,Repair Work Done U Type of Pump 601fet-SrbiEH.P. j ' State Work Done 1,hS�s'/L P�.w� .%n .RepNe •- <br /> Well Destruction © Well Diameter o� M Sealing Material i Depth: Pdt rt well <br /> Depth 4ID19 Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R"dence Y Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: - Water table depth (' <br /> SEPTIC TANK. O Type/Mfg Capacity N f. <br /> PKG. TREATMENT PLT.❑ ' � Ertl o.� <br /> Distance to nearest: Well Foundation Pr R <br /> - � MA, 1 1993 T <br /> LEACHING LINE ❑ No. 6 Length of lines Total lengt, BAN <br /> FILTER RED © Distance to nearest: Well Foundation �'M"EAEW SERVICES <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> ,DISPOSAL PONDS ❑ t <br /> 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 <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."Contractors 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 II for all requi ed inspections. Complete drawing on reverse side. <br /> y 7. . _,C <br /> Signed x. Title: �'� Data: <br /> F DEPA E - <br /> Application Accepted by Dasa �RArea 4;1/26' <br /> r`� <br /> Pit or Grout Inspection by Date Final Inspection by Date __+_^ <br /> Additional Comments: ' <br /> Applicant pReturn all-copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box-2009, Stkn, CA 95201 <br /> INFOFEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY. DATE PERMIT7N0. <br /> . EH t3- (REV.Y/r 51 <br /> Elf t1-357a <br />