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4 ry, Ap' <br /> APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISIIFD W <br /> (Complete in Triplicate) <br /> Application is hereby made to Sam 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 Regulatione of San <br /> X4Joaquin County Public Health Services. <br /> L� <br /> Job Address /� ` / "� `S .City <br /> Lot Size/Acreage <br /> �(Ownar's Name LAWREAI(jr_- -SO4i$? RQ _ Address 1� �f�/ Phone <br /> h' <br /> N _ RContractor /;fS- <br /> Phone <br /> TYPE OF WELLIPUM : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER G& Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROPP. if� �yN/tam <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS rp /..S-/ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open aottom ❑ Manteca Dia. of Well Excavation Din. of Well Casing <br /> ( <br /> Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing_ Specifications <br /> i'1 Public F1 Other' _4 171 Delta Depth of Grout Seat Type of Grout <br /> I I irrigation ^.Approxbl Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth i, Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living unit: Number of bedrooms <br /> Character of soil to a depth of 3 tool:I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Comportments <br /> v <br /> PKG. TREATMENT PL.T.O Method of Disposal �+ <br /> Distance to nearest:,. Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of linea Total length/size <br /> FILTER BED Cl Distance to nearest:, Well Foundation Property Line <br /> SEEPAGE: PITS 11 Depth � Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ y, <br /> I hereby certify that I have prepared thin 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 tot become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I unify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> kSigr*d <br /> he applicant t call fpr fired inspections. Complete drawing on reverse side. <br /> Tide: _ >�ie�S LaEI1rT Date:� FOR DEPARTMENT USE ONLY �� { <br /> Application Accepted by Dots Z Z Area <br /> Pit or Grout Inspection by Date Final Inspee ion by Data <br /> Additional Comments: e"& <br /> Applicant - Return all copies to: San Joaquin-County Pub11c'He 1th Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0-Box 2009, Stkn, CA 95201 <br /> FEE INFO �A[�MOUNT DUE i� AMOUNT REMITTED �'CASH <br /> RECEIVED BY DATE^g 14RiMI GNU. \ <br /> . EH 13241RFV.r/etil �Tt[Z0� �p� iC7� � �� " !4C` J�J <br /> EH 14.26 '•/ - <br />