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s <br /> ' APPLICATION FOR PERMIT"— <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 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 is 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. /r <br /> q D �, f 1 r G Lot Size/Acreage VL <br /> Job Address _ - �`j� City A� <br /> (A, Address 573 [ S1 /y f � L Phone <br /> Owner's Name � a <br /> Cantrattor ��-r"- ��'t^-��+ddress � `L �� � �ense Na. G ��� �Phone Co' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELLREPLACEMENT ❑ DESTRUCTION Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well n <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 T <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing i <br /> Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing. Specifications <br /> Il Public Cl Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P. State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Naterial i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR 1ADDITI l I TRUCTIO o seplic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence�f_ Commercial— Other t '� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: W e depth ` <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments r�\ <br /> PKG. TREATMENT PLT. Gl Method of Disposal �\ f <br /> Durance to nearest: Well Fou- ' ' n Property Line I <br /> 1 <br /> LEACHING LINE Cl No. & Length of lines - Total length/size <br /> FILTER BED ❑ Distance to nearest: oil Foundation Property Line <br /> c • <br /> SEEPAGE PITS 11 <br /> �Dzuna;t, <br /> Size �-. Number <br /> SUMPS nearest: Well Foundation Property Line <br /> DISP SAL P ❑ ' <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 Sen Joaquin County 1, _ - r <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: "1 certify t'n the performance of the work for which this permit is issued, I shall employ persons subjim t to workman's compensa- <br /> tion laws of Califorrtls.". <br /> The applicant call f r r Inspections:Complete drawing on reverse side. L <br /> Signed _Title: —-1 1 _ Date: 3-1 i <br /> f OR-DEPARTMENT USE ONLY 71 t 3 7� <br /> Application Accepted by qC �* Date Area S { <br /> 9 <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> ( <br /> Additional Comments: -� <br /> Applicant - Return all copies•to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> FEEINFO AMOUNT DUE AMOUN REMITTED K ECEIVED BY DATE PERMIT'N0 <br /> EN 53-24(REV.i/ 31 <br /> FH 14•�e21-2- 7 Q ",L&fML <br />