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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)46$--3420 <br /> A P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 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 /> t Joaquin County Public Health Services. <br /> Job aAddress z.' 4r� �/y City Lot Size/Acreage <br /> , -, 3 /- ' <br /> Owner's Name �}2'/r'a/1Address __ r + Phone <br /> Contractor 7&j2:�J�ddress J Z&���� N� Phone /D r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T ❑ DESTRUCTION 0 Out of Service well ❑ <br /> -PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> C FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />{ <br /> 0 Industrial . O Open Bottom ❑ Manteca Dia.of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> i'1 Public Cl Other n Delta Depth of Grout Seal Type o1 Grout <br /> I i Irrigation w Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Purnp N.P. Stale Work Done'_ <br /> Well Destruction ❑ Wall Diameter Sealing Material L Depth .� <br /> Depth Filler Naterial i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION OT REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> t t available within 200 feet.) <br /> Installation will serve: Residence L Commercial' Other I r <br /> Number of living units•. -I— Number ofr s # # <br /> Character of troll to a depth of 3 feet: `t Water table depth <br /> SEPTIC TANK.. x O i Type/Mfg' 3 Capacity i 19 Compsrfinerits' <br /> PKG. TREATMENT PLT.0 <br /> DMethodif <br /> sal <br /> Distance to rtebrest: Well Foundation -- Property Line =T <br /> LEACHING LINE Cl No. b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wetl,140e4 Foundation Z? Property Lina <br /> SEEPAGE PITS i I Depth _Sire Neber. <br /> SUMPS LI Distance to nearest: Well/_'t__2L Foundation Property Line <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 regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the lollowing: "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: 1 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 musySA r all uir n irons. Co drawing on reverse side. <br /> 7 <br /> sigr+ed rile: _ � _ _ Date: �� <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptid by -[� �-'c��r��c Date Cr—'9'X Area ',z-2- <br /> 6 f <br /> Z--itr Grout Inspection by atsZ/3 a �f z Final Inspection by k e, _ Date A/-�2- <br /> Additional Comments: <br /> Applicant - Return all copies to'. -San JoaquinCou q Public Health Services- <br /> Environment <br /> ervices"- <br /> Environmental ealth Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE 1 <br /> )NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 6H 13-24• EM1!•7a1R�.fixSJ 3 2 <br /> t <br />