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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 L t>r o <br /> / P O BOX 2009, STOCKTON, CA 95201 f <br /> ��,n,€.1t7t� 4 <br /> PERMIT E%PIRE 1 YEAR FROM DATE SU 11 <br /> (Complete in Triplicate) A6� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork 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 32 52 Z•- City S r0(� 4744C Lot Size/Acreage /!__ <br /> . 'i Z)61 rar4.e� ll'f5 LO s4#46�UO ;A 5 r � 1(b5- 36• -2- <br /> Owner's Nama � j ��• 7b�L'pddress Sy '• 4S,� 1 I-1 tic lP­&- Phone 7 <br /> Contractor Address License No, Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION C} Out of Service Well <br /> _ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitors ❑ <br /> DISTANCE TO-#EA ST: SEPTIC TANK SEWER LINES DISPOSAL FLD, �-PJW LINE <br /> tiN9ATI0N AGRICULTURE WELL 01H .WEt� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ­PR©BLEM AREA COfy.STRttCTFON SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca- Dis. of Wall Excavation Dia. of Wail Casing <br /> [I Domestic/Private ❑ Gravel Pack -C'Tracy Type of Casing_ Specifications O <br /> (1 Public C] Othar- f1 Delta Depth of Grout Seal ~- _ Type of Grout <br /> I i Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Dont L7 Type of Pump H,P. State Work Done <br /> Well Dettiuction 0 Well Diameter Sealing Material i Depth ~� <br /> i Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADOITION I 1 DESTRUCTIONX INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> -6­ Aillill"ve: Residence-X- 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 JM__Type/Mfg ua f Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest. Wall Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number C <br /> SUMPS LI Distance to nearest: Well Foundation Property Line �1 <br /> DISPOSAL PONDS ❑ <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 reguiations 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 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 applicant�01�111 for �equirad���rawing on reverse side. <br /> Signed �-L Title: , <br /> Date: <br /> FOR DEPARTMENT USE ONLY -ClApplication Accepted by c Date ��'� LJ I_I- <br /> Area / <br /> fv !bfyy -6c -f—IE wu1 <br /> Pit or Grout Inspection by Data Final Inspection by tr Date <br /> pazL m s ,q is v C s` �jyn2.r, �-j,� �✓2•�kC i.JCcS <br /> Additional Comments: / <br /> r <br /> Applicant - Return all copies to: San Joaquin County public Health Services C <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2049, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE AERMiT'NO, <br /> INFO CASH <br /> . E124114EV.iinsl <br /> EHH l4.s�2a S N , 010 r �r <br />