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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �T ✓ 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT MIRES 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. / n <br /> Job Address 0: City L oL Lot Size/Acreage <br /> Owner's Name 1.M Address � �C 1�t&JIS Phone <br /> Contractor �- AddressJ License No.�6;J�Phone <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT DESTRUCTION O Out of Service well O <br /> PUMP INSTALLATION O SYSTEM REPAIROTHER O Monitoring well U <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 /> C) Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private O Gravel Pack --CI-Tracy Type of Casing_ Specifications <br /> 1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. S State Work Done <br /> Well Destruction O Well Diameter `,��+ Sealing Material i Depth <br /> Depth r , Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sower is <br /> ' available within 200 feet.) <br /> Installation will some: Residence_ Commercial_ Other - <br /> Number of living units: Number of bedrooms w <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~MSNT- <br /> Distance to nearest: Well Foundation Property Line n <br /> LEACHING LINE O No. b Length of lines Total length/size AUG 19 1992 Z_ <br /> FILTER BED O Distance to nearest: Well Foundation Property L",N-41PAO�,j! +=' ,{ „ <br /> SEEPAGE PITS I I Depth Size Number ENVIRONMENIAL1-1E�tCilrt 1-`iv;'S i!0`4 <br /> SUMPS LI Distance to nearest: Wel 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 ordinnces,state laws, and <br /> rules and regulations 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 cpmpensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifiesthe fo#? :"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 <br /> The sppliesn call for all requir nspectio s Complete drawing ona <br /> de, 4� <br /> Signed Title: Date: <br /> FOR DEPARTME SE ONLY <br /> � <br /> - - - ---- - _ - V-7-7, <br /> - - <br /> - DateAnnrea-- <br /> Ph or Grout Inspection by Date Final Inspection by ���Gc. Date Z <br /> Additional Comments: <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 /> IEEE I FO A/M.Or�UNT DtlE A UNT REMtTTEO CK 8 <br /> ASH ,,RECEIVED 6Y ATE PERMIT*NO. <br /> . EH 1321InEV.1�11Ii1 � `f( TIV <br /> EH t4de Vlu <br />