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APPLICA1I0N EOR PERMIT <br /> 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 /> PERMIT EXPIRES 1 YEAR FROMDAM „ISSUED <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 <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 Servl ea. <br /> Job Address City Lot Size/Acreage <br /> w is Name .1 P � P)�&ELj:�ddress Phoneq& <br /> r <br /> on c r <br /> - ( y Lt�1Add Uti/L' LUe EEo. IY�V VJPhone"6 6� � <br /> TYPE OF WELL/PUMP: I1NEW WELL ❑ WELL REPLACEMENT .. DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION El SYSTEM REPAIR OTHER ❑ Monitoring Well C3DISTANCE 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 /> CI Industrial ❑tOpsn.Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> -6amemic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i'1 Public 1=1 Other n Delta Depth of Grout Seal Type of Grout <br /> - <br /> I 1 Irrigation Approx. De l I astern /Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. e x State Work DO <br /> Well Destruction O Wel! Diameter Sealing Material i Depth <br /> Depth Filler material i Depth Pvmf <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial'` Other = <br /> Number of living units: Number of bedroom) <br /> Charactar of sag to a depth of 3�feec_ 4,,.. Water table depth <br /> SEPTIC TANK. 0 'Typi/Mfg t Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ i r Method of Disposal <br /> Dlstance to crest: `' Wellt­ Foundation Property Line <br /> it <br /> LEACHING LINE Ell �No. a Length of linea "" Total length/size J'�^ <br /> FILTER BED 0 ;Dista6a o nearest., Well Foundation Property Line <br /> 1 "`— �1' j <br /> SEEPAGE PITS 11 !Depth Size Number <br /> SUMPS UI !Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 Sen Joaquin County <br /> Home owner or licensed pant'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.wo_rkman's_compensation laws of Californa.`CopgactOt3 <br /> i -hjrirl9.or sub-contracting signature <br /> certifies the following: "1 certify thst itits n performance of the work for which this permit is issued, 1 shall employ persons subject tc'workmsn's•compsnsa• <br /> tion laws of California." <br /> The a a t st ca r uir lnspactions. Complete drawing on rev side. JOA-AA <br /> Signed Title: Date: <br /> FO DEPARTMENT USE ONLY �f r <br /> Application Accepted by I Date 4� �" Area 0 ` <br /> Pit or Grout Inspection by Data Final Inspection by <br /> r <br /> Addhional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/3ervices <br /> 445 N San Joaq-u fn.,,P Boz 2009, Stkn, CA 95201 <br /> (I}FEE AMOUNT DUE AMOUNT RR]EMITTED CK RECEIVED BY TE PERMI7•N/O.. <br /> . EH 1 (REV,t i N 61 Y <br /> FH f4764-M 1 fff��� <br />