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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 lnstaLi the work herein described. This <br /> application is made in Compliance 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 �' W, rY•a}, sT' City 73KA Cy ___ Lot Size/Acreage <br /> Owner's llama TEy e Address Phone 8,3,§-s-Ire 0 <br /> Contractor So Address wz j�LNP �``► /9License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA,....CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I 1 Eastern Surface Seat installed by <br /> Repair Work Done IJ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing llaterial A Depth r`t <br /> Depth 111ler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONI DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence L Commercial_ Other <br /> Number of living units: AV Number of bedrooms e <br /> Character of soil to a depth of 3 feet: ah r ADAM ('2 —' -"_?2240D 7ta-4; ater table depth /`5, <br /> SEPTIC TANK. 0 Type/MfgPYP4'0 CA 5 r p� Capacity ety No. Compartments <br /> PKG. TREATMENT PLT.❑ t* Method of Disposal <br /> Distance to nearest: WelI'le '-P Foundation 8 Property Line 100 + <br /> g length'/size `��� <br /> LEACHING LINE 1A No. b Length of tensa � "'" �� � Total <br /> 'd� <br /> FILTER BED ❑ Distance to nearest: WeII �`� Foundation Property Line 3C� <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundstion r _Property Line_ <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this application and that the work wilt 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: "l 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 workmen'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 shad employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> ► OR.DEPARTMENT USE ONLY <br /> Application Accepted by (9 <br /> Date Area <br /> Of <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: d t� <br /> Applicant - Return all copies to: San Jo-9—in County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, 0 Boa 2009, Stkn, CA 95201 <br /> FEE INFO <br /> AMOUNT DUE AM/OfUNT RE�MIJTTEU `CK RECEIVED BY. [� DATEG QPERMIT'NO. r <br /> EHt}211REV.tinSt_r /f�..7( <br />