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i ,ATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9201 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PRQ9 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 d?'cribed. <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regu,ltione of <br /> Joaquin County /Public Health Services.. <br /> \Job Address1Yf1ff `City Lot Site/Acreage <br /> �Owner's Nem fkuuwdress Anwah0AXPhone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 171 DESTRUCTIONX Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f.1 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casin <br /> U Domestic/Private O-Grovet O Tracy Type of Casing Specifications--- <br /> M Public 1'1 Other Delta Depth of Grout Seal Type of Grout_ <br /> CJ Irrigation [ —.ApprOx. Ds h Eastern Surface Seal Installed by <br /> Repair Work Done pa ot�ump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth ON <br /> Depth Filler Material i Depth r� O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ DDITION O DESTR TION GI INo septic system permitted if public sew <br /> available within 200 feel.) <br /> Installation will serve: Residence_ Commercial__._ Othe <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well (ndaflon Property Line <br /> LEACHING LINE O No. b Length of lines Total length/size <br /> FILTER 13ED n Distance to nearest: Well Found tion Property Line <br /> L <br /> SEEPAGE PITS 11 Depth Si: Number <br /> SUMPS LI Distance to nearest: ell Foundation Property Line <br /> DISPOSAL PONDS O <br /> - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, V..,ats laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's sigriature certifies the following: "I certify that In the performance of the work for which this permit is 3susd, I shelf not r <br /> employ any person in such manner as to become subject to workmen's compensation laws of Calif ornia•"Contractors 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 wri non's compensa- <br /> tion laws of California." <br /> The applicant must call Jor all required insPections. Complete drawing on reverse side. <br /> Signed Xs{7r art Title: Date: T �Q9Ct <br /> , <br /> Application fQR DEPARTMENT USE ONLY Application Accepted by 1-al ,� Date Area _ <br /> Pit or Grout Inspection by Date__,.Final Inspection by Dats r ` <br /> Additional Comments: _ <br /> Applicant - Return all copies to: SAN JOAQUIN IINTY LIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE CIOAMOUNT REMITTED CCASH K If RECEIVED By DATE PERMIT NO. <br /> fREV., it,) ( � (gyp t ro <br /> 4 Amp, r <br />