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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 MIRES 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 work herein described. This <br /> application is made in ccelpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County- t_-/ftblic Healthy Services. <br /> Job Address. 3,/ 21 f iq b ____—..__ City Lot Size/Acreage <br /> Owner's Name L,� Q � Address Phone <br /> r <br /> Contractor WJq Address cense No.V Phone S <br /> TYPE OF /PUMP: NEW WELL ❑ WELL.REP C ION ❑ Out of Service ll ❑ <br /> PUMP,-INSTAL-LATION-O— w SYS 67f , EPAIR � �� 5 Monitoring ell ❑ <br /> �l11[[_ _. /LIQ jay P P. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER �� H Oi�I��V,El�j•�TII <br /> FOUNDATION j AGRICULTURE W�� dhW UMPS <br /> INTENDED USE TYPE: OF WELL, PROBLEM AREA CONS TAU CTION-SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑-Manteca Dia. of Well Excavation pia. of Well Casing .ml <br /> �5 atic/Private ❑ Gravel Pack ❑ Tracy i Type of Casing Specifications <br /> e4bt fa Other n Delta Depth of Grout Seal Type of Grout <br /> 4 69 ._Approx. Depth I I Easterh Surface Seal Installed by 1 <br /> igQr Done 0 Type of Pump 1H.P. State Work Done r..I <br /> ction ❑ Well Diameter °Sealing Material i Depth <br /> Depth hiller Material i Depth <br /> CV4EPTIC WORK: NEW INSTALLATION I I REPAIR/ADDtTION kL—DCgTRUCTION l I INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> 'Instal nwill serve: Ince commercial the( <br /> I <br /> living units: Numbevof r ms - <br /> I of soli to a depth of 3 fast:t f _ Water table depth i <br /> EIC NK. t4f�ypilMfg Capacity No. Compartments <br /> T TMENT PLT.❑ -t Method of Disposal i <br /> ZC1} Distance to nearest: Well Foundation Property Line <br /> C� 4 I <br /> cr.+4CHING LINE ��No. 8 Length of linesi f _` _ �-� Total lerigthlsize <br /> OLTER BED ❑ Distance to nearest: , well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size e�� X Number <br /> SUMPSL�Bf�tanca to nearest: Well Foundation i ropsrty Line <br /> DISPOSAL ADS Cl <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 lam, 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 tfte 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 Is 1 o alifom . f <br /> The applican st ull f r al u i t' mplete drawing on r verse si <br /> Sig Title: ., Date: <br /> r <br /> 7R PA USE ONLY <br /> '�-Application Accepted by Date 4 Area <br /> Pit tx Grout Inspection by t E Tt!_ pection��Hb� F Data <br /> L S3 <br /> L!G HrrA i <br /> Add'nional Comments: ENV�nON,1 <br /> ...----Applicant--.Return-•all-copieswto-, SR a7thrLP �WBsvic�> - n. — <br /> 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 A`� <br /> (o- a, ?!G <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY �+ DATE PERMIT,NO. r� <br /> . EH 1}ZI Ir1EV.V,- S ' t �' �j �� T93— D (8 <br /> , " TEH 16m ( 7 <br />