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APPLICATION FOR PBRHIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE S <br /> (Complete in Triplicate) <br /> Application is hereby made to &w Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi as. <br /> Job Address i 2491p QMCL City Lot Size/Acreage <br /> Ron <br /> r'• Na� Address Phon <br /> LL <br /> MQml��J E~ 4v {� ` 2^� <br /> actor_ _- Wi�l_�W�__ ess��z� (_,Js� Wcense No. Phone t i-3 G � <br /> TYPE OF WELL/PUMP: NEW WELLL0�0/ WELL REPLACEM NT C-1 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATIONS SYSTEM REPAIR 0 OTHER ❑ Monitoring Well L-3DISTANCE TO NEAREST: SEPTIC TANK _ / SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L1 II dustrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �`Bdmestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications <br /> VI Pt(bllc 171 Other (l Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigatiort ___.Approx. Depth I L Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump N.P. _.__ Stat4 Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth 7�f7� Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) �\ <br /> Installation Will serve: Residence— Commercial— Other ►v <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth %0 <br /> SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments Q <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest:- Well - --Eoui+dation Property Line <br /> LEACHING LINE [❑ No. EI Length of linea Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEOAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to-nearest: Well '-Foundation Property Line <br /> DISPOSAL PONDS ❑ ( yy <br /> I hereby certify that I have prepared this application and that the work will be do a in accordance with San Joagtiin`county ordinances, state laws, and /4 <br /> rules and regulations of the Sen Joaquin County A. <br /> Home owner or licensed agent's signature cenifies the following: "I certify that in the performance 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 sub-contracting signature <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 Cal' is." <br /> The applican tail f r NI r, ad inispections. Complete drawing on revs side <br /> Sig Title: Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date ':k-4_.Q—12, Area d f <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental45NSanJoa Health Permit/Services <br /> 445 R Sea Joaquin, P O Sox 2009, Stkn, GA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED ASH. RECEIVED BY DATE PERMiT'NO. <br /> EM 1}24(IIEV.1/h SI O r <br /> 91_:36sl <br />