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APPL I CAST I ON FOR PERI!I T <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 /> PERMI—EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application in made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Addresst2?Z;&.F, Cit Lot Size/Acreage <br /> Owner's Named m4Address Phone <br /> Contractor Address r �gz""4. .�ri2� _� es a No,.T_Wa 14%9 Phone2.y <br /> i�2� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION P-' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> ,.r <br /> --Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i►TPrivate plrravel Pack L7 Tracy Type of CasingF�P . V51— <br /> Domestic/ -- - Specifications <br /> I1 Public Cl Other ❑ Delta Depth of Grout Seal ^? Type of Grout <br /> 1 I Irfigation Approx. Depth Ikstern Surface Seal Installed by <br /> Repair Work Done U Type of Pump 5118 H.P. 3-1-1-1 'fA _ State Work Done_. <br /> Well Destruction ❑ Well Diameter Sealing Naterial i Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTION I ] lNo septic system permitted if public sewer is <br /> available within 200 loot.) <br /> Installation will serve: Residence— Commercial_ Other t <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments \��+ <br /> PKG. TREATMENT PLT.❑ Method ofsal <br /> Distance to nearest: Well Foundation ProPr MENRYT <br /> LEACHING LINE ❑ No. S Length of lines Total gangi <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pr L a <br /> CAN IN COUNI <br /> SEEPAGE PITS 11 Depth Size Nuff pug&AC HF-AL <br /> SUMPS LI Distance to nearest: Well Foundation _ E.NVIWt} I <br /> DISPOSAL PONDS ❑ <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 /> Home owner or licensed agent's signature certifies 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title' !/ y�,�l� -l�JJJJa v1 Date: :2' <br /> OR DEP <br /> Application Accepted by Date Ar <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: v v t <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental. Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DVE A OUNT REMITTED C K RECEIVED BY TE PERM17'NO. <br /> • EM113.74 tIIEV.1/"5) — 9 <br /> Ftf t4•2s J <br />