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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (219)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMITEXPIRES_ 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 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 �. �-`C "4/ � A :7� City "�� Lot Size/Acreage <br /> wner's Name -49 �' Addresses ��'er.�l+ Y L��'. `*" Phone <br /> 1X Contractor" 21 c ' � " Tddress ��✓f'�,fa � /�r�'�Mkxo` License No. fv�-�-�2 Phone -'7 5 � <br /> - -� <br /> rrr\\\ <br /> 'TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION (�"`* SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing <br /> C l Domestic/Private ❑ Gravel Pack FJ Tracy Type of CasingSpecifications J3 <br /> III P I CI Other n Delta Depth of Grout Seal Type of Grout <br /> rngation Approx. DepJh 1 I Eastern Surface S ni Installed by <br /> Repair Work Done U Type of Pump Z <br /> H P, -5' f� State Work Done _ <br /> Well Destruction ❑ Weil Diameter Z22 " Sealing Material i Depth N� <br /> Depth Filler Material. i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i 1 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Ll No, S Length of lines Total lengthisize y�1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number R <br /> SUMPS LI Distance to nearest: Well _ Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 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 cenifies 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 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 California." <br /> The applican . ustt c ll four all r uir ins coons. Complete drawing on reverse side. <br /> % Signed X L7'i� �'P ! r <br /> A/ <br /> . 9 Title: ���'a Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by ''�► Data <br /> i 1_.. <br /> Area b� - �- <br /> Pit or Grout Inspection by Date Final inspection by Z-<�J e`"'"Bate <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health rervices <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 Ylv <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13.24• EH 14.20 V.rinsi <br />