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A <br /> ,A,PPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES FRQM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made-to Son 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. /J <br /> Job Address �� City - Lot Size/Acreage 7 4-r <br /> Owner's Nome �' ""�� � �Address Poona <br /> Address _License No. Phone e�7� <br /> Contractor -- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION -) Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ lsonitoring 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 /> n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. o}Well Casing <br /> Cl Domestic/Private C! Gravel Pack7 ❑ Tracy Type of Casing_ <br /> Specifications <br /> I.I Public [I Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth i I Eastern Surface Seal Installed by V <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing <br /> Material Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 7 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence s' Commercial Other <br /> t <br /> Number o1 living units: _-,LNumber of Dom '2—e [ �k A" <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. L9r'Type/MfgrQZ---Qkj. opacity <br /> �No. Compartments 2-- <br /> PKG. <br /> PKG. TREATMENT PLT.❑ f P Method of Disposal <br /> Distance to nearest: Well 15-0 Foundation Property Line r <br /> S <br /> LEACHING LINE We-1 o. b Length of lines �` I Total length/size <br /> FILTER BED Cl Distance to nearest: Well _ Foundation -3•i Property Line <br /> c <br /> SEEPAGE PITS 14—Depth "-T Size Number <br /> SUMPS LI Distance to nearest: Well a2 r Foundation Property Line R <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 Sen 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 subcontracting signature <br /> certifies the following: "I certify that is the performance of the work for which this permit is issued, I shall employ persons subject to workman's componss- <br /> tion laws of California." <br /> The appliccall`for all requir i sp!c' ns. Complete drawing on reverse side. <br /> Sigma Title: 4OAiDate: <br /> FOR DEPARTMENT USE ONLY l} <br /> Application Accepted by Date = Area ©Z 1)— <br /> /Payor Grout Inspection bye ata Final Inspection by <br /> uDate <br /> b(((///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 Hoa 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED) I CK 8 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . 6"tis,IrtEv.�,et r , l l 6/a33— <br /> t M 14.36 <br />