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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 )KoJ-,—V7)3 Zo-Z'76S-55 <br /> (209) 468-3447 <br /> Dui CCK 5;u4&0 <br /> YEAR rR99 PATE-100M <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. Thin <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 d t)lq Rules and Regulations of lien <br /> Joaquin County Public Health Services. ell /79 —�,}„��• <br /> Job Address <br /> : City � Lot Size/Acreage <br /> Owner's Name Address �70 � /Yl(340'7�� Phone WgZMt <br /> Contractor <br /> icense Ncr t5-J -Phone ` L <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION CI <br /> PUMP INSTALLATION 0 SYSTEM REPAIR C] OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. / if h <br /> FOUNDATION AGRICULTURE WELL OTHER WELL7— <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private D Gravel Pack 0 Tracy Type of Casing s I <br /> T Public I"1 Other O Delle Depth of Grout Seal o rout 4, <br /> CI Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth 19 f•I j7�If <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> available within 200 lest.) <br /> I <br /> Installation will serve: Residence__ •Commercial — Other 9 <br /> Number of living units: Number of bedrooms <br /> depth <br /> table dep <br /> Character of soft to a depth of 3 feet: � Water f' f <br /> SEPTIC TANK..- - ❑ Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT,C7 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line l <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED r n Distance to'nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 pertormance of the work for which this permit is issued, I shall not <br /> i 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, I shall employ persons subject to workman's compensa• <br /> Ilan laws of California." <br /> t The applicant I cap for al red inspections, Complete drawing on reverse side. <br /> x <br /> Signed Title: <br /> 6 . 6 - L•�IData: Z�S <br /> k FO DEPARTMENT USE ONLY <br /> Application Accepted by Date ~��� OLS <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOjKUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 85201 <br /> FEE I AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NO. <br /> INFO <br /> �I . tH 1324)REV.rinSr —7 <br /> EN^,t,.20 <br />