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,f <br /> I APPLICATION FOR PERMIT <br /> 3 . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> i <br /> (209) 468-3447 X—Q <br /> PgMi j EXPIRES I YEAR FROM DATE MUM <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. Thie <br /> application is made in C 'liance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r <br /> �(p (�ZZL <br /> Owner's Nam __ City Lot Size/Acreage <br /> Jab Address .,� f <br /> .IIII A dress ~Phone <br /> e <br /> Contractor �A l t�[ LI� _ ae��lAddress License No. � Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION�C7 ---,SYSTEM REPAIR ❑ OTHER O Monitoring Well C1 <br /> DISTANCE TO NEAREST; SEPTIC TA?4K SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL `PROBLEM AREA y1 CONSTRUCTION SPECIFICATIONS <br /> fl Industrial 0 Open Bottom !©L Manteca- !Dia,of Well Excavation Dia. of Well Casing <br /> ` 11 <br /> I L) Domestic/Private L1 Gravel Pack I C] Tracy, Type o1 Casing Specifications <br /> t M Public 1:7 Other I 1'0 Delta =Depth of Grout Seal Type of Grout <br /> CI Irrigation IM Approx,-Depth d Ess—ter—Z,' Surface Said I f t lled by <br /> Repair Work Done V Type of Pump H.P, State Work pone <br /> f +"-Sealing Material i/Depth 41 <br /> Well Destruction 0 Well Diameter -, r <br /> Depth 'Filler !Material i'lkpth <br /> -tif � <br /> TYPE OF SEPTIC WORK: NEW iNSTALLAT10N PArR/AOOITiON 77��DESTRUCTJON G INo septic system permitted if public sewer is r <br /> � \�< ` available within 200 feet.) <br /> installation will serve: Residence ,—. Commercial l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: CA r` / // Water table depth <br /> SEPTIC TANK. ❑ ,Type/Mfg __.. C>�,((a V'L� Capacity_ No. Compartments <br /> PKG. TREATMENT PLT.❑ _ Method of Disposal <br /> Distance to nearest: Well Foundation .Property Line <br /> LEACHING LINE 63 4tu71 Length of lines - < ' Tota!length/_size <br /> FILTER BED rl Distance to nearest: Well Foundation Prapeity Une_ V <br /> SEEPAGE PITS epthSize N/mbar <br /> _ <br /> ' SUMPS ` LI 4ti-nei to nearest::Well _ Foundation Property Line <br /> DISPOSAL PONDS ❑`�j •i tt .1 i f 1 ► k `, . - <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 ' } ' I <br /> Home owner or licensed agents signature certifies the following: "I certify that in the performance aftthe work for which this permit is issued, I shall not <br /> employ any person in sudli rril 6 r as-Cp become sul5r6 to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> e i9� 'ea the following: I certify thstthe performance of thi work for which this permit is issued, I sempoy persons subjectp <br /> �in hall lto workman's com ensa- <br /> tI Is of California." ��' i E <br /> " <br /> The applies a t call or I1 r fired i pectin plats drawing on r eras side: 1 t <br /> a <br /> Signe Titie: P Date: <br /> FOR DEPARTMENT USE ONLY � <br /> i <br /> E 2� <br /> Application Accepted by �� - �, Date '�Z` Area C, <br /> Pit or Grout Inspection by Date Fine[ Inspection by Date L f <br /> Additional Comments: ' - <br /> f Applicant - Return all coMpiss to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONUENTAL HEALTH DIVISION PIERHIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> IFEEE <br /> NFO AMOVNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. <br /> 1i <br /> . CH 13•24IREV.I/K5) , t�11,r0� 6G� �f""1�9 � Ct <br /> fM;4.26 U I d <br />