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` N <br /> ' APPLICATION FOR PERMIT <br /> li SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ii PERMIT EXPIRES 1 YEAR FROM„DATE ISSUED <br /> II - <br /> (Complete in Triplicate) <br /> I Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> ma <br /> application is de in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules "d Regulations of San <br /> Joaquin County Public Health Services. ^� <br /> Job Address ® C' 11'h7 �. /Z_0 __ City rY__-- Lot Size/Acreage <br /> Owner's Name t1' ICddress 54M(l Phone 3 <br /> r <br /> Contractor G P w Address License Nos C7 1-3_Phone7`61"�� <br /> TYPE OF WELL/PUMP: �I NEW WELL © WELL REPLACEMENT F1 DESTRUCTION Cl Out of Service Well Cl <br /> i PUMP INSTALLATION I" SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAR EST.-SEPTIC.TANK 'SEWER.LINES DISPOSAL FLU. PROP. LINE <br /> FOUNOAT_ `- -- AGRICULTURE WELL OTHER WELL PITS/SUMPS {� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y <br /> El Industrial 0 Open Bottom G Manteca Dia. of Well Excavation--4 Dia. of Well Casing <br /> l'.l Domestic/Private 0 Gravel Pack El Tracy Type of Casing_ Specifications <br /> I'1 Public Ia Other n Delta Depth of Grout Seal Type of Grout <br /> Ili,.<Gation _.Approx, Depth i I Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump %ti�1� �Le H.P. / Z S--AtP -- State Work Done - U <br /> Wed Destruction O Well Diameter Sealing Material i Depth t 77,or N41"Zi <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> { II i a4ailable within 200 feet.) <br /> Installation will sero: Residence_ Commercial a Other <br /> i Number of living units. Number of bedrooms <br /> Character of sod to a depth of 3 feet: Water table depth <br /> ! 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: ' ! <br /> Well -.`• ' z Foundation I t ,Property Line <br /> LEACHING AE ❑ go..B Length of lines � Total length/size <br /> FILTER BED Cl Distance to nearest: :Well Foundation-_:,� Property Line <br /> SEEPAGE PITS 11 Depth Site ' Number <br /> SUMPS ?� L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS t O <br /> 'I hereby certify that 1 have prej ared this application and that the work will be done in accordance with San Joaquin county ordinances, stele laws, and <br /> rules and reguiatkm of the San Joaquin County " <br /> Home owner or licensed agent's signature cenifiss-the'foliowing: "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 isauad, I shall employ persons subject to workman's compensa- <br /> tion lawn of California." II 1 <br /> The applicant must call for all required ' do . Complete drawing on rev aid <br /> Signed Title: Date: �Q �! <br /> - -- <br /> OR PARTMENT USE ONLY <br /> Application Accepted byCIO _ Date Area a - <br /> Pk or Grout Inspection by II Data Final Inspection by Date .3 <br /> Additional Comments- �I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> ii -445 N San Joaquin, P O Boa 2005, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. <br /> • EN 14,28 <br /> ILA <br /> rinEl <br /> EH 1�•2a 1 <br /> to <br />