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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE S <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 cosrpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Jab Address ►► o City e* Lot 81ze/Acreage <br /> Owner's Name <br /> 2 e. rfl CQ I tL' Address Phone <br /> Ma �— <br /> Contractor r 1 T Address 7�_ L1 icense NoADRDS3 _Phone -a� <br /> CTION ❑ out of Service Well ❑ <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPkACEMENT n DESTRU.�.,.�.-.-._r.PUMP_INSTALLATIQN.� f,.SYSTEM REPAIR.C7 OTHER p monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD._ -,--- PROP. LINE 2L�+ <br /> FOUNDATION , �S AGRICULTURE WELL OTHER WELV�i PITS/SUMPS I WSJ ` <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> 04 Industrial Open Bottom ❑ Manteca i Dia. of Well Excavation Dia. ofn Well Casing <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing � w 5pecificadons <br /> t G � <br /> Il Public I'1 Other I-1 Delta Depth of Grout Seal T Grout <br /> I Irrigation CWQ.Approx. D�epth_ A �1 1 Eastern r + urfabe Saul Installed by r r• e <br /> Repair Work Done L] Type of Pump ..��� ]— H.P. �� $ - _ State Work Done_ k <br /> Wetl Destruction ❑ Well Diameter.; Sealing Material i-Depth <br /> Depth Filler Material i Depth �. t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIA'DDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> } available within 200 lest.l f <br /> Installation "serve: Residence____ 'Commercial— Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Y Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i a <br /> PKG. TREATMENT PLT. LMethod of Disposal! t <br /> r <br /> Distance to nearest: Well f Foundation Property Line � <br /> LEACHING LINE C1 No. 8 Length of linea ""wj— ..Total-length/.size } R <br /> FILTER BED 0 Distance to nearest: Well F Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size f' = Number <br /> SUMPS LI Distance to newest: Wall Foundation Property Line <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 f i <br /> Home owner or licensed agent's signature certifies the following: "j 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 i 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 CalNornla." <br /> The applicant must call for 011 wired inspeAtions. Complete drawing on reverse side. ' f <br /> S /I Title: � �-� <br /> FOR DEPARTMENT USE ONLY 4' 3 <br /> Apphcstion Accepted by Date Area T_ <br /> I <br /> Pk. rout spection by to -� `� Final Inspection by Dates S <br /> AddhIcinal Comments: 11.5 r <br /> ' x <br />! €Applicant - Return all copies to: San Joaquin County Public Health Services f <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Hox 2009, Stkn, 6A'95201 3 <br /> FEE <br /> AMOUNT DUE AMOUNT REMIT-Ct:D'ems' RECEIVED-BY— <br /> IN 17.24 iREV, <br /> 0 i n sl <br />' EM 1�•2e <br />