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+ APPLICATION FOR PERMIT • <br /> F SAN JOAQUIN COUNTY- PUBLIC HEALTH SERVICES� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9,5201 <br /> (209) 468-3447PERMIT EXP <br /> F , <br /> (Complete is 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 rade in compliance with San Joaquin County Ordinance No. 549 aq 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 24iSS IV. Cc, t7,Fa <br /> O►� � <br /> Job Address 60,tu-pe 0-✓ a!`Iru oAW T- CitY f_�iC_�Y gw <br /> Lot Size/Acreage <br /> Owner's Name f b ti°VAdd(ass -_ (0 y C..CU17'pa CcTL [L,rPhone W <br /> Contractor C _Cy50_ �� <br /> Qf �Pf" _Addre C License No. 3;-it Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION Out of Service Well 0 <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> U OomesticlPrivate ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public 1-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> El Irrigation —.Approx. Depth ❑ Eastern Surface Soul Installed b N <br /> Repair Work Done 0 Type of Pum dZi <br /> P State Work Done <br /> Well Destruction ❑ Well Diameter ming Material 14 Depth <br /> Depth - C2:OV -94�. Filler Naterial i Depth Fill EIlAt <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION G (No septic system permitted if r sew �s <br /> available within 200 feet.l <br /> f Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> 4 - <br /> Character of soil to a depth of 3 fset: Water table depth <br /> ' SEPTIC TANK .0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line 0 <br /> r SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> m 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 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 iseued, I shall employ persons subject to workman's compensa" <br /> "On 'awa of Caldornla." <br /> The applicant at call,for req d ' spections, Complete drawing on res se side A <br /> Signed Title: - Date:�2 L <br /> FOR EP TMENT USE ONLY <br /> Application Accepted by nate 171 <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 6S <br /> Additional Comments: `j <br /> aV <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES - <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT Ot1E A OUNT REMIT-TED CASH RECEIVED BY DATE PERM17'N0. <br /> . EN 13.24IREV,1/451L S QC) I <br /> EN 1676 " 9� 1 <br /> t <br />