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t� <br /> APPLICATION FOR PERMIT <br /> 4 f` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �.� 445 N SAN JOAQUIN, PHONE (209)4683420 <br /> JD P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT-EMPIRES Y YEAR FR(ZX DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct end/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 Beryl ea. <br /> Jab Address City Lot Size/Acreage <br /> Owne►'s Narrie4} /'1 7' �F -��/ �� Address t �'® Phone <br /> Contractor <br /> }� ress License No. [ic'm 4�!2--Phone j0511 <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT C7 DESTRUCTION t of Service well Cl <br /> PUMP INS7ALLATiON 0 fYSTEM".REPAM Cl`' �. OTH R'❑ Monitoring Well [3 <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL -OTHER WELL PITS/SUMPS " <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS + " <br /> ❑ Industrial ❑ Open Bottom . ❑ Manteca Dia- of Well Excavation Dia. of Well Casing ' <br /> EI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 11 Public FI Other I n Delta Depth of Grout SealType of Grout <br /> IL I I Irrigation Approx f Depth I I Eastern Surface Seal Installed by y '` <br /> Repair Work Done CJ Type of Pump H.P. LL y State Wo k DOrte. % -_ J <br /> Well DestructionWell Diameter Sealing-Mat&ri&1=4_Depth CA504FZcaZ <br /> ' De th �9 L filler Material,i Depth r 2&a,, <br /> p <br /> TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR IADDITION-1,1 DESTRUCTION I I (No septic system permitled if public sewer is . `\ <br /> available within 200 feet.lr <br /> Installation will serve: Residence Commercial_ Other + � � <br /> Number of living units, Number of ballroomstA <br /> Character of sap to a depth of 3 feet: Water table depth <br /> SEPTIC TANK b Type/Mfg -Capacity No. Compartments '� q <br /> PKG. TREATMENT PLT.❑ f' Method of Disposal T <br /> Distance to nearest: Wel Foundation Property Line <br /> LEACHING LINE ❑ No. 3 Length of lines ' Total length/size <br /> ,.FILTER-BE0 ❑ . Distance to nearest: Well ---Foundation Property Line K <br /> SEEPAGE PITS I ) Depth, Size Number. - <br /> SUMS LI Distance to nearest: Well Foundation Pr,6perty Line <br /> DISPOSAL PONDS ❑ `� <br /> I hereby certify that I have prepared,this application and that the work will be done`rn accordance w6h,San Jbaquin county ordinances, state laws, and <br /> ruf•i and regulations of the San Joaquin County , � <br /> Home owner or licensed-agent's Awature certifies the following:'I certify that in the p6Ho mance of the w6ik for which this permit is issued, I shall not <br /> nr <br /> eb_ ,.any person in such manner-as to4become subject to work man4-compensation-laws 61 California." Contract0i's hiring or subcontracting signature <br /> cerfifiis the following:"I certify that In tha performance of the work for ch this permitis issued, I shall employ persons subject to workman's compensa-, <br /> tion laws of California." <br /> ,,.-The-applicsa requi t s. Complete drawing on iev�r side. <br /> Signed " Title: F _1 Date: <br /> FOR DEPARTMENT USE ONLYApplication'/Accepted by F Dots / Area <br /> Pit or Grout Inspactlon by Date Final Inspection Dat4 <br /> "kdditiona ommants: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental:Health Permit/Servi-ces <br /> .ii 445'N- San Joaqui:A, P O Box 2008, -Stkn, CA 95201 <br /> FEE <br /> INFO /AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> 60 Z <br /> EM 14411 !G' <br />