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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 /> k9 (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR PROM 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// 5ServicesA <br /> /� <br /> 7D , � age <br /> Job Address s � /t. City � � w Lot Size/Acre 1ACC <br /> Owner's Name - 11229 <br /> r*s Address 7O���' S k1&4 .' J Phone <br /> Contractor "r-: � "~�fAddressD�� k License No.142-373 Phone v�474 <br /> TYPE OF WELL/PUMP: NEW WELL O/ WELL REPLACEMENT n DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION rPl SYSTEM REPAIR O OTHER O 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 /> Cl Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public I"1 Other O Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done e Type of Pump ZiuC�1/fG H.P. ZOO State Work Doneru O14 rfA4%lfor <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION 0 DESTRUCTION CI (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 O Type/Mfg Cap ty No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well >Xtion Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth S' Nu r <br /> SUMPS LI Distance to nearest: ell Foundation Property Line <br /> DISPOSAL PONDS O <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 li ed ag is 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 on in such nner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> conifiet t ollowing: ­I ce Ify that in t orm e f the work for which this rmit is issued, I shall employ persons subject to workman's compensa- <br /> tion law f Calif. rola." <br /> The a licant call r all r r C plate drawing on v i e. ��++ <br /> Signs 9 Q Title: pate: <br /> DEPARTMENT USE ONLY 2 <br /> Application Accepted byT,D�_ Vim- - ��) .. ! Dat —CAI Area <br /> Pit or Grout Inspection by Date Final Inspection by D <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AM LINT REMITTED. RECEIVED BV OA3E PERMIT'NO. <br /> INFO <br /> . EH 17.2 INEV. iMsI C, <br />