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'r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVI TAL ALTH DIVISION <br /> P O BOX � STOCKTON, CA 9.5201 <br /> (209) 468--3447 <br /> RIfTT EXPIRES <br /> YEAR SROM DATE ISNED <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. M yyy� <br /> X905 pQ City�r � 'Lot Size/Acreage r � AC <br /> Job Address - n� j� �^�/ <br /> • t/lt;r� Address t •�` CLIA LFii - Phone7` <br /> Owner's Name r-�pQ,/� <br /> �5 MY.�L� �• J ense No. Phone k6: 'E 1� <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 0DESTRUCTION u) Out of Service Well. Cl 4 ; <br /> PUMP INSTALLATION Q <br /> SYSTEM REPAIR ❑ OTHER Ac °itorinLmwC] <br /> DISTANCE TO NEAREST; SEPTIC TANK _� � -- SEWER LINES IM)' DISPOSAL FLD.� PROP. LINE , 1 <br /> FOUNDATION AGRICULTURE WELL I OTHER WELL�...� PITS/SUMPS 400" <br /> INTENDED USE TYPE OF WELL OROBLEM AREA CONSTRUCTION SPECIFICATION5, °l <br /> n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> of Gro %42=0"Z <br /> M Public I"1 Other 0 Delta Depth of Grout Seal <br /> ;a Irrigation Approx, DepthTyp i�JCr�f <br /> 0 Eastern Surface Seal Installed by. �`�� ' <br /> �"'�'��'• <br /> Repair Work Done C] Type of Pump H.P, State Work Done — C <br /> Well Destruction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION G lJNo,septic system peeet.)sd if public sewer is, <br /> available within 200 Iat.I to; <br /> Installation will serve: Residence _ Commercial ;-.Other + 1 <br /> .. C <br /> Number of living unite Number of bedrooms A <br /> Character of soil to a depth of 3 feet: MENT Water tali]* depth <br /> SEPTIC TANK D Type/Mfg <br /> Com ED i No. Compartments <br /> f PKG. TREATMENT PLT. G7 Method a1 Disposal t° <br /> Distance to nearest: Well FoundaKA- <br /> IQ 1Froperty line <br /> j <br /> F LEACHING LINE 0 No. 8 Length of lines -r'A <br /> FILTER BED [-1 Distance to nearest: Well �_ � ��IA (NAl F# M dfryf"Llne <br /> SEEPAGE PITS 11 Depth 5i:e Number <br /> SLIMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this application and-thit-the work wilt-be- wo-in-aczordence-with-San-Joaquin-county-ordinarices,,state-laws;and- <br /> rules and regulations of the San Joaquin County <br />+ Home owner or licensed agent's signature cenifies the fotlowing: "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 Ca4fornia." Contractor's hiring or subcontracting 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 workman's companaa- <br /> tion laws of California." <br /> The applicant must call for all,r/egquuired i pections. Complete drawing on reverse side. <br /> JIo ;� Title: kG+ 7�! Date: <br /> Signed x, -- <br /> R DEP A MENT USE ONLY <br /> 2Date 3 �- A <br /> t Application Accepted by /c <br /> Pit or Grout Inspection by Date Final Inspection by� Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICI3S <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 65201 <br /> r FEE AMOUNT DUE AMOUNT REWTTED CASH <br /> RECEIVED BY DATE PERMIT'NO. <br /> INFO j <br /> a EH 13-24tREV.+/K6! "•' <br /> _7 <br /> /-ad <br />