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n APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> k _ (209) 468-3447 <br /> T ESPIRES 1 XfiAR DATE I.SSUID `,AN 2 <br /> (Complete is Triplicate) j �llt 'f Ifo- <br /> Application is hereby made to San Joaquin Count for P �` <br /> q y permit to construct and/or install the vorK- erkiPt deecr bed:. <br /> application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Aegulatione`of,Sanr <br /> Joaquin County Public Health Services. <br /> X39 l � <br /> Job Address 1. ��` _— City Got Size/Acreage <br /> Owner's Nam „_ Address Phone <br /> c pP�� - Yl _ cL <br /> Contractor f Address pp 1A. 6- q3O Ly[icense No. L6 2- Phone 832r_22�j 1 <br /> TYPE OF WELL/PUMP; .. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Hell D <br /> PUMP INSTALLATION SYSTEM REPAIR A OTHER 0 Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL t` PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ZOomestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public Cl Other 0 Delta Depth of Grout Seal Type of Grout <br /> M G Irrigation a—Approx, Depth ❑ Eastern y Surface Saw Installed by -..I <br /> Repair Work Done Type of Pump.$_ H.P. Stole Work Dona <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth V ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION L-I DESTRUCTION M (No septic system permitted if public sower is <br /> available within 200 feet.} /Y <br /> j Installation will serve: Residence— Commercial— Other <br /> i Number of living units: -.Number of bedrooms _ _ . �^ '- _ 4 <br /> Character of$04 to a depth of 3 loot: Water table depth <br /> '.1.4-SEPTIC TANK: 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 ' ' J <br /> Method Of Disposal <br /> Distance to nearest: Well Foundation Property Line �} <br /> 'S <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line �~ <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ID <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 /> rulesand regulations of the San-Joaquin County <br /> Home owner or licensad agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I she not <br /> s Compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to workman' <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must col t r all required inspections, Complete drawing on reverse side. <br /> Signed Title: _ did _ Date: J= 1 <br /> 1 <br /> FOR DEPARTMENT USE ONLY /� <br /> Application Accepted by Date Area ` <br /> Pit or Grout inspection by Date Final Inspection by Date `3 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> FEE CK IT <br /> ?NFO . AMOUNT,DUE AMOUNT AEM17ED /CSA � RECEIVED BY �DA�TEPERMIT'NO, <br /> . EN 14.21 I REV.I/n y) .. C... %4 .{ M I ! f <br /> EH;1.2e I Od,J�[ t <br />