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APPLICATION FOR PERMIT � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> I RIt IT &MIRg5 1 YEAR ORQX "TE I§S ED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> f application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Q� r< City S'�X Lot Size/Acreage <br /> Jab Address - <br /> za <br /> I Owner's Nama Ga.s/ &"C—' '` 0 �^ Address Phone <br /> Contracto <br /> Address r0[ f7�/ 7� License f77 Phone <br /> TYPE OF WELLIPUMP: NEW WELWELL REPLACEMENT Cl 4 DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATIOZ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well El <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS AC <br /> n Industrial 0 Open Bottom Cl Manteca Dia: of Well Excavation Dia. of Well CasingYY� <br /> DomesticlPrivata1 Gravel Pack L7 Tracy Type of Casing �'LC ( -- —. Specifications <br /> I, R Public .. Cl Other ❑ Delta Depth of Grout Seal of Grout <br /> Type <br /> G Irrigation 1-44P­Approx. Depth f] Eastern Surface Seal installed by <br /> i Repair Work Done ❑ Type of Pump H. State Work Done <br /> Well Destruction O Well Diameter sealing Material i Depth <br /> Depth Filler Material b Depth <br /> x TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION CI (No septic system permitted.if public sewer is <br /> available within 200 feet.) <br /> i Installation will serve: Residence— Commercial _. Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: } Waler table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity + -No. Compartments <br /> PKG, TREATMENT PLT. 0 i K ethod of Disposal <br /> Distance to nearest: Well Foundation I Properiyrlina <br /> LEACHING LINE ❑ No. & Length of lines Total length/sspre <br /> FILTER BED [=1 Distance to nearest: Well Foundation r Property Line <br /> F <br /> SEEPAGE PITS 11 Depth Sire Number <br /> 1 SUMPS LI Distance to nearest: Well; Foundation 1 Property Line <br /> 5 � <br /> DISPOSAL PONDS ❑ Alf <br /> ' .` I hereby certify that I have prepared this application and that,the warlcwilt be done in accordance with Soh Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County r. : .t. <br /> t . Home owner or licensed agent's signature certifies the followin-g: 'I certify that in the performance of the work for which this permit is issued, I shall not <br /> I amploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> F candies the following: "I certify that in the performance of the work for which this permit is issued,!l shall employ parsons subject to workman's compensa- <br /> tion laws of California." 'F <br /> The applicant must call for al requlf inspections. Complete drawing on reverse side. <br /> Signed x ! �:C.c� �1., - - --}v Title: Date: <br /> i R D -USE ONLY <br /> Cl:)D � l7 Area <br /> Application-Accepted-by- - ,l -- -Dasa . <br /> f Pit or Grout spsction by `' LN r© _ Date! '��Z` 'Final Inspection b t `rv- � D <br /> Additional Comments: — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> I 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REWMID CK RECEIVED 6Y DATE PERMIT NO. <br /> INFO CASH Z <br /> i . EH,13-24INEV.I/n61 <br /> '` EFI'426 <br />