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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468_2"� ,-2_0 <br /> PERMIT R"IRES- _i YEAR VM PATE ISSU yP <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 /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> i Joaquin County Public Health Services. ` <br /> Job Address.��;1'72 J EIFaKoirr, oqAli—= _ -- City Lot Size/Acreage <br /> Owner's Name Address to Phone �^ o <br /> i Contraclot Address '" License No. `' Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ 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 /> fl industrial CDiam <br /> " ❑ Manteca Dia. of�Well Excavation Dia. o} Well Casing <br /> U DomeaticlPnvats L7 Tracy Type of Casings Specifications <br /> M Public Delta Depth of Grout Seal ' Type of Grout <br /> CJ Irrigation pth t Eastern Surface Seal Installed by <br /> Repair Work Done U H.P. M1 �-- State Work DoneWelt Destruction ❑ i Sealing Material k Depth <br /> Depth Filler 1Miterial,!,Depth <br /> " r V <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION❑ RE IR/�AODITION CI DESTRUCTI ❑ INo septic system permitted if public sewer is <br /> l available within 200 feet.1 <br /> Inatallatipn will serve: Residence^ Commercial,. -. 0 er"'" "�"" "" "` �• -�- " '" <br /> Number of living units: Number of bedrooms x <br /> Character of soil to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Cepa ty-} No. Compartments ' <br /> PKG. TREATMENT PLT,0 Method of Disposal <br /> k <br /> Distance to nearest_ Well Found ion Property Line <br /> f <br /> I LEACHING LINE Cl No. & Length of lines Z Total length/size <br /> FILTER BED ❑ Distance to nearest:; Walt Foundation Property Line ' <br /> r � <br /> ' SEEPAGE PITS 11 Depth Size mbar <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby comity that I have prepared this application and that t e 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 Itowing: "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 laof Cali a Is <br /> The a licant must ail for equir_ inspections, Complete drawing on reverse side. <br /> Signed X T1t10: � � Date: <br /> TMENT USE ONLY I��1 <br /> Application Accepted by Data ' Area 1 <br /> Pit or Grout Inspection by Date Final Inspection by Date 14') x, <br /> Additional Comments: f S v <br /> Applicant — Return all copies to: ff 47 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL-H£ALTH DIVISION PERMIT/SERVICES <br /> ' 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> CKFEEt <br /> INFO AMOUNT DUE OUNT REMITTED CA�SH RECEIVED BY DATE C� PERMIT NO. <br /> . t[H A-7�IREV.,,ns) �0O`7 <br /> CHA-24 <br /> ll <br />