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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009 ' STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> CA <br /> le?:112� <br /> icate) <br /> P , nJoaquin <br /> o� y <br /> Applicat on hereb made to San Jae uin o t aet and/or install the work herein described. This <br /> application a l=ade in cc4liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services411 0-1 . �f <br /> � ID" 2 7' Lo Size/Acreage <br /> Job Address City <br /> I �. <br /> Owner's Name rV �h Address 6re,&Att5f SAXX�m-- Phone <br /> Canirattor� rn CT7 ^Address �6v License NoEgL� .S0; --Phone �tte5 1J�� i <br /> TYPE OF WELL/PUMP: `p NEW WELL C7' WELL REPLACEMENT C-1 DESTRUCTION ❑ Ll <br /> PUMP INSTALLATION C] SYSTEM.REPAIR 0 OTHER Cl WI <br /> I C1 1 <br /> ��INALLA � B�2.tNG <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. L1NT�ST <br /> �t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Public fa Other ❑ Delta Depth of Grout Seal Type of Grout T <br /> M Irrigation ,_XApprox. Depth 'Cl Eastern Y Surface Seal Installed by r/FSO wrc.L t1,f( <br /> Repair Work Done U Type of Pump H.P. State W& Dona _ K< <br /> Wall Destruction C3Well Diameter Sealing Materiel i Depth <br /> Depl#i' Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRJADDITION M DESTRUCTION CI (No septic system permitted if public sewer is ' <br /> Iavailable within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other - - <br /> Number of living units: 1 Number of bedrooms -- Y <br /> Character of Boll to a depth of�3 feet: Water table depth " <br /> SEPTIC TANK. ❑ Type/Mfg - Capacity No. Compartments <br /> t <br />` PKG. TREATMENT PLT. 0 iIN� Method of Disposal <br /> l Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED CI D14-tance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS I I Depth Sire Number = ' <br /> I <br /> SUMPS L'I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <br /> I hereby certify that I have prepiied 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 /> Homs 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 <br /> QU <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 /> I certifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa- <br /> tion laws of California." $1 <br /> The applicant mus call f r all r wired inspect. ns. Complete drawing on reverse side <br />" Signed X 14 Title: Date: <br /> FOR DEPA TMENT USE ONLY / <br /> !' Da r- r <br /> Application Accepted by atAreaC!h�, <br /> Pit or Grout Inspection by II' Date Final Inspection b Date <br /> I Additional Comments: <br /> t e <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> II 445 N SAN JOAQUIN, P O BOA 2009, STOCKTON, CA-95201 <br /> FEE AMOUNT DUE AMOUNT REMIT7ED CK RECEIVED BY DATE PERMI7'NO. <br /> INFO CASs <br /> , EH 13-24IREV.+iKei <br /> CH 74Z! ► il' <br />