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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y <br /> (Complete in Triplicate) <br /> Application le hereby <br /> made San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coWliance vith San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ��� ^.'� " _ City Lot Site/Acreage <br /> Job Address cin in s <br /> r� �.��• �� � �O `•`�Jr�,.i:. Rhone <br /> Owner's Name ^� r,� �"� Address - - � <br /> k Z� � <br /> Conttactof <br /> Address ZS_7 �' A License No. `-- 'none _ <br /> TYPE OF WELL PUMP: NEW WEL WELL REPLACEMENT 7_1 DESTRUCTION 0oCiut;of,Service"Well x: l <br /> M6nitoring:uell <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ = ; <br /> i DISTANCE TO NEAREST: SEPTIC TANK 11 S _ SEWER LINES y DISPOSAL'FLD��- PROP. LINE <br />', FOUNDATION "�AGRICULTURE WEkI--- ` OTHER'WLL .pf7S/SUMPSL! <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. o}Well Casing `rQ �} <br /> C� Industrial Apert Bottom ❑ Manteca Dia. of Well Excavation r <br /> Type of Casing Specifications <br /> omeatic!Private ❑ Gravel Pack ❑ Tracy ? - ! <br /> L'1 Public I Other ❑ Delta Depth of Grout Seal YDe of Group r R Y <br /> Ci Irrigation �.Approx. Depth ❑ Eastern Surface Said Installed by V <br /> H p State Work Dona <br />` Repair Work Done U Type of Pump --- -., _ _" - ----- <br /> Well Destruction O Well Diameter . __� Sealing Material i Depth F <br /> 1i <br /> Depth Filler Material a Depth t <br /> { TYPE OF SEPTIC WORK: NEW INSTN O REPAIR 0 DESTRUCTION D INo septic system permitted if public sower is <br /> ALLATIO <br /> # available within 200 feet.) s ; <br /> Installation will serve: Residence Commercial _-„^ Other <br /> Number of living unite Number of bedroom$ <br /> �Sterts�;�be <br /> Character of soil to a depth of 3 feet: depth <br /> No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> I Capacity <br /> PKG. TREATMENT PLT. ❑ AJ Method of Disposal <br /> Distance to nearest: WeN dation _ �' Property Line <br /> LEACHING LINE ❑ No. & Length ofilines r7otal length/size <br /> FILTER BED n Distance to nearer[: all Foundation Property Line - <br /> a.r.,.` Number <br /> � <br /> SEEPAGE PITS 11 Depth -7- o.-near <br /> Sue <br /> SUMPS L1 Di$tan o:;aeras[:; Well. Foundation Property Line <br /> DISPOSAL PONDS ❑ s. 1 lyvl i <br /> e spared this applic5tiob and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> I hereby comity that I"a <br /> rules and regulations 0101he Ssn`Joaquin County r <br /> Home owner o►licensed agent's signature eertifiesahe..lollowrngr� I certifVlliaf in the rformance of the work for which thipermit is issued, I shall not <br /> j employ any person in such manner as to becom subjectrto-wor4Cman's,compensation taws of California."Contractor's hiring'or sub-contracting signature <br /> eartiliea the following: " carts Shat in the performance iif"�'i-work for whith this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California <br /> The applicant must qutred in - cti �pIo$e'drawin <br /> Signed �r Date: <br /> Title: <br /> l I <br /> k r _ A�ITMENT USE ONLY <br /> ffff Date _91Area <br /> 4 Ap ' tion Accepted by ,.. <br /> Pit or Grout Inspection by CL esFinal Inspection by Data <br /> 4 <br /> A 1, <br /> y/f ""'"• i�`-." '—___._�,-.._...,�-,�..-�•---.:.,.,...r � _ k <br /> Additional Comments: <br /> Applicant - Return 811 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 HOX 2009, STOCKTON, CA 85201 # <br /> 3, CK RECEIVED BY DATE pEAMIT'NO. <br /> FEE <br /> INFO OUNT DUE AMOUNT REMITTED CASH <br /> . EH1724tREV.Iinb) 560 <br /> FN:�•2a <br />