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Mx. <br /> { <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> I (209) 468-3447 / 1:3106 1190--1060 '417 <br /> ES I YEAR DATE . ISSUED aPIre,9,0N <br /> F (Complete in Triplicate) <br /> I <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 Services. <br /> GLS{, QrE L N 1 ' City 'DNLot Size/Acreage <br /> Job Address I <br /> Owner's Name I-���'�-�`'t <br /> t`it S r Address ��0 wt Phone 7 <br /> Gonlractor � y r <br /> ' A'1 resS 20Z5 06AS License No. �� Phone <br /> _ � <br /> i TYPE OF WELLIPUMP. NEW WELL C1 WELL REPLACEMENT n DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER X <br /> DISTANCE TO NEAREST:-SEPTIC TANK SEWER LINES DISPOSAL FLD. P9490-611045 === -3 w-S <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> ELL INTENDEDUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 11 x.14— -A <br /> fl Industrial 0 Open Bottom O Manteca Dia. of Well Excavation <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing S WlGt � 4L <br /> M Public 1-1 Other CO Delta Depth of Grout Seal W (r <br /> CJ Irrigalion _Approx. Depth 0 Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Sealing Material & Depth <br /> Wolf DesDestructionO Well Diameter FI•rGG' +.iT <br /> Piller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION I-] DESTRUCTION Cl avlailabptic systele shin m permitted <br /> matted if public sewer is <br /> 4 Installation will serve: r Residence— Commercial— Other L)3 <br /> Number of living units: Number of bedrooms " I <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments <br /> fPKG. TREATMENT PLT. C7 Method of Disposal <br /> Distance to nearest: Well Foundation. Property Line <br /> LEACHING LINE ❑ No. iii Length of lines Total length/size <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire 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 wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> i Home owner or licensed agent's signature certifies the following: "I certify that in the periormancs 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compansa•r <br /> tion laws of California." <br /> j The applicant st call for It red inspections. Complete drawing on reverse side, <br /> ` Signed x ._ Title: /S Date: U <br /> FORD�TMENT USE ONLY 'L1 e <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Fi I inspection by oats 3 2f <br /> Additlonsl Comments: 2.. <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I S Ip <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �O <br /> 445 N SAN .10AQUIN, p 0 BOX 2008, STUCKTON, CA 85201 <br /> EEEAMOUNT DUE <br /> AMOUNT REMITTED CKS CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH 13•7/INEV.1/MSI <br /> EH 71.26 <br />