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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> YEAR PROM <br /> --DATE ISSUM <br /> (Complete in Triplicate) F-A!o�. <br /> Application is hereby made to San u t@ <br /> Joaquin County for a permit to construct and/or inatak,,v6iX :here in descrlbe'd.`-'This <br /> application Is made In Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rule's amd'Re"ticons of San <br /> Joaquin County Public Health Services. <br /> Job Address City -40d,' Lot Size/Acreage <br /> Owner's Name Address &4--)0 eI4 Phone <br /> Contractor Address AYZ- Al, <br /> A&Icr ease Ncl&a/ Phone,c/6 If I <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACE NT Ll DESTRUCTION EI Out of Service well D <br /> PUMP INSTALLATION C SYSTEM REPAIR OTHER 0 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 /> Service <br /> S <br /> _ in <br /> F� Industrial 0 Open Bottom —Manteca Dia. of Well Excavation Dia. of Well Casing <br /> W/Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public 1-1 Other 0 Delta Depth of Grout Seal <br /> M Irrigation — Approx. Depth Type of Grout <br /> 0 Eastern Surf lace Seal InstaNad by <br /> Repair Work Done L3 Type of Pump H,P. State Work Done d 0 <br /> Well Destruction El Well Diameter Sealing Material i Depth <br /> Depth ,,. /0(es - Filler Material i Depth <br /> TYPE OF SEPTIC WO-K; NEW INSTALLATIONDESTRUCTION CI INo septic system permitted it public sewer is <br /> Installation will serve: Residence— Commercial _ Other available within 200 last.) <br /> Number of living units: — Number of bedrooms <br /> Character of soil to a depth of 3 feet: ;,1,1sd ,1 public sewer 4,s <br /> Water table depth <br /> SE.PTtC TANK 0 Type/Mfg <br /> PKG. TREATMENT PLT 0 Capacity_ No, Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE 0 No. & Length of lines _ <br /> Total length/size <br /> FtLTER BED CI Distance to nearest: Well Foundation _ Property Line 70 <br /> SEEPAGE PITS I Depth Size <br /> SUMPSNumber <br /> LI Distance to nearest: Well Foundation `Li <br /> DISPOSAL PONDS 0 Property <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 a <br /> Home owner or licensed agent's signature certifies the following: ,, certify that in the performance of the work for which this permit is issued, I shall not <br /> GMPIOY 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 partofmance of the work for which this permit is issued, f sh6li employ persons subject to workman's compensa- <br /> tion laws of California," <br /> The app drawing on reverse side, <br /> Signed Title: Date: -or <br /> A DEPARTMEN SE ONLY <br /> Application Accepted by 4L- <br /> Date Area <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: -L-S' <br /> Applicant - Return all copies to; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> FO, <br /> 114 T M!EN SE <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 95201 <br /> FEE <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> SH <br /> RECEIVED By DATE <br /> EH 13.24(FIEV. <br /> EH -.4-20 2 <br /> 94- <br />