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-. ..., - -• :=dam <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> k ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES IYEAR FROM DATE ISSUED <br /> (Complete is T'rplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application Is made in eoffiliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. . !� <br /> Job Address � J_ + li�^r�! v�+ City Lot Size/Acreage �3 5 <br /> Owner's Name r- 'I .U oS Address K.Jt+k"Phone S -3.947 <br /> t y //• J <br /> Cont(ailiir;-TM. Address t0 r icense No, Phone <br /> KTYPE OF.WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUFF107PRQXt of Service Well ❑ <br /> PUMP INSTALLATION ❑ ,,rSYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />? FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications { `Il public;, 1:1 Other 171 Delta Depth of Grout Seal Type of Grout 4" ` <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by \ <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> t Wan Destruction ❑ Well Diameter Sealing Material i Depth <br />( Depth Filler Material i Depth _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION E I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installatan will serve: Residence___ Commercial_ Other <br /> t <br /> Number of living units: Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water;able depth <br /> I <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING Total Iongth/siz-e �- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I t Depth :{_` Size ` x Number <br /> SUMPS Ll Distance-to nearest Well F AFound_ation Property Line ' <br /> DISPOSAL PONDS ❑ f .`m <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 /> rules and regulations of the San Joaquin County <br /> Homerowner or licensed agent's eignaturs oertifie�lite following: {I artity that in the performance of the work for which this permit is issued, I shall not <br /> anlpby any person in such manner as to become.subject to workman's compensation laws of California."Contractor'6 hiring or sub-contracting signature <br /> cartilies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ perscnrsubject to workman's compensa <br /> tion lawn of Calif ia." <br /> Thsippticant call uir pactions. Com late drawing on reverse side. p <br /> Signs <br /> Date: f <br /> . i <br /> FOR DEPARTMENT USE ONLY <br /> F � r <br /> Application Accepted byta..� Date L� Area ©Z Z r N <br /> Pit or Grail Impaction by Data Final Inspection by Date <br /> Additional Corrtrriehts:-- '� ^-�-�-•�i.�•----.-•--�:���_. . <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> t Environmentil'Heaith Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED K ECEIVED BY ATE PERMIT'NO. <br /> P <br /> . EN 14.74lREV.s/R5i �C `d (a v1`5&o ` <br /> FH 114-211i (P � i- L <br />