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+ y <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 XFAA FROM D T ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cortjplitutce with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Heath Services. <br /> Job Address City Lot Size/Acreage <br /> �Q�w>� � . Address` Phone 'ZINa % <br /> Owner's Name, I <br /> I <br /> 14 <br /> Contractor �� �F Address % i License NoALENUIN _Phone <br /> TYPE OF WELL/PUMP: i�' NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well L-1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <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 <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing { <br /> X Domestic/Private ❑ Gravel Pack E7 Tracy Type of Casing Specifications \ <br /> I'] Public fl Oiher fl Delta' k Depth of Grout Seal Type of Grout <br /> I I Irrigation JApprox. Oe th I I Eastern ` Surface Seal Installed by <br /> Repair Work Done U Typal of Pump H.P. ._ ` --'= Stria Work Done 't►\t�` tn����R���te.Q. <br /> Well Destruction ❑ Well'Diameter Sealing Material i Depth <br /> Dep fh Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION 114No septic system permitted it public sewer is <br /> .I I available within 200 feet.1 <br /> Installation will serve: Resid ince 2"/Coinmercial_r Other,' <br /> Number of living units: Number of bedrooms <br /> Character of sols to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> _PKG.-TREATMENT PLT.❑ Method of Disposal �. <br /> r d <br /> Distance to nearest: Well.• '-Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ ; Toiai length/sue <br /> FILTER BED Cl Distances to nearest: Well`* !f Foundation ,,Property Line <br /> 47 <br /> r .! <br /> 4 SEEPAGE PITS 1 I �th Size .` Number <br /> t SUMPS CI ance to nearest: Wen <br /> Foundation 1r "'"'Prop. Lina <br /> DISPOSAL PONDS ❑ �! d <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 r <br /> rubs and regulations of the San Joaquin County <br /> Horne owner or licensed agent4 signature certifies the following: "i certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such tnanier as to become subject to workman's compensation taws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I csrtify khat in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws Of California." I; <br /> The applicant must call for an required in"ptions. Complete drawing on reverse side. <br /> l Signed II� Title: ►1Z��. Date: <br /> I I . <br /> e FOR DEPARTMENT USE ONLY } <br /> Application Accepted by Date l Ar l <br /> l <br /> Pit or Grout Inspection by I� Date Final Inspection by Datrrr� Z� <br /> Additional Comments: I� <br /> li <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED _ K RECEIVED BY DALE PERMiT NO. <br /> INFO f <br /> • Eµ13• t1IEV.tieSY 168 <br /> � EN i4.M>d 1 fk 'h <br /> t <br />