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4 APPLICATION FOR PERMIT <br />`y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 1� ENVIRONMENTAL HEALTH DIVISION <br /> a' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA' 95201 <br /> PERMIT EXP I RE5 I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> L <br />' Application is hereby dada 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. 51+9 and 1862 and the Rules and Regulations of.San <br />` Joaquin County Public Health Services. <br />[ of <br /> Job Address City Ole �a Lot Size/Acreage <br /> ILII �` <br /> i Owner's Name Ad s A- Phone <br /> r Contrera moi! Address rV r !(r� ,! '`'License Nof z�7-7 Phone (0d _5(P <br /> r <br /> I TYPE OF WELLIPUMP: I� NEW WELL ❑ a WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ;❑ <br />! PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPT IC 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 /> ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing t <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ ,-Specifications <br /> T1 Public (_1 Other n. Delta Depth of Grout Seal -!'°-Type of Grout �— <br /> hI I Irrigation l�AppFax. Depth I I Eastern.-,a• Surface Seal Installed by <br /> G Repair Work Done U Typa of Pump s ,H.P.' - L „ -Sta`te Wo►FDbne T <br /> Well Destruction ❑ WtHI'Diameter Sealing Material i Depth <br /> Depth M11et-Materi'rtl i Depth - - <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAlR 1 DDITION -f DESTRUCTION I I (No septic system permitted it public sewer is <br /> J �` available within 200 feet.) <br /> Y Installation will serve: Residence A' Commercisl OthAr x <br /> Number of living units: J Number of r ms ,... <br /> 'Character of soll to a depth of 3 feet ti _µ} .> _ Water table depth <br /> SEPTIC TANK. O Type/Mfg Gspacity" No. Compartments <br /> PKG. TREATMENT PLT. ❑ X11; j - Method of Disposal ` <br /> -XDktanee to nearest: Well - Foundation Property Line r .r <br /> I 'FJ' <br /> - 7 r <br /> LEACHING LINE Na. 3 Length of lines/:71D Total length/size q0Z <br /> FILTER BED ❑ Distance to nearest:, well .Foundation Property Lina .ate <br /> e) th <br /> SEEPAGE PITS DSize �. /.�P �"Gr,.....--•--- Number 7��Line — , <br /> L^ ' <br /> SUMPS LI Distance to nearest: Vl�all Or - Foundation ALU ^_ Pro C`� <br /> DISPOSAL PONDS <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> G rules and regulations of the San Joaquin County <br /> Homs owner or licensed agent'ssignatura certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> t4 employ any person in such manna►as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> f certifies the followino: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject.to_worknlan'■compensa <br /> tion'"of California.'• e — --- - _ _ ,--. - r_ r- - <br /> The applIca Cali for !! it n".ctions. Complete drawing on reverse side 2 <br /> Signed. Title: -Dat <br /> FOR (DEPARTMENT USE ONLY '' ff <br /> Application Accepted by Date �� Area <br /> &or Grout I y �� �� Date_Z_ 3 <br /> Impaction b ate Finsl inspection by � <br /> Additional Comments: 'I�I <br /> „I. <br /> Applicant .- Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> J' 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EK 1121(REV.i/Rsl <br /> EH 11.20 L <br /> it _ <br />