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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)468-3420 <br /> 0 <br /> P O BOX 200931 STOCKTON, CA 95201 ' <br /> PERMIT EXPIRES 1 YEAR FR OII DATE ISSUED 4 <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 in made in Compliance vith San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> c� <br /> Job AddressCity Lot Size/Acreage <br /> Owner's Name Addres ne O <br /> Contractorc4-U109?XA "r Address Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION D Out of Service Well <br /> PUMP INSTALLATION q SYSTEM REPAIR.❑ OTHER q Monitoring Well q <br /> DISTANCE TO NEAREST: SEPTIC TANK -- SEWER LINES DISPOSAL FLD&C!t-_ PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r� <br /> INTENDED USE TYPE OF WELL '—PROBLEM"AREA"-"'"CONSTRUCTI-ON-SPECIFICATIONS---- E.� <br /> ❑ Industrial ❑ Open Bottom Manteca--Pia. of Well Excavation Dia. of-WelI Casing S <br /> 1:K Domestic/Private Gravel Pack .❑ Tracy Type of Casing _1 L Specificatio4al!"r <br /> f'1 Public C1 0f r i Fl Delta Depth of Grout Sealtype of Grout <br /> I 1 Irrigation ' Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Watl Destruction O Well Diameter r Sealing-HAterial 6,Depth i <br /> �� Depth .: filler Material li Depth j l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1-, REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> F available within 200 feet.) <br /> Installation will sews: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth # j <br /> SEPTIC TANK. 0 Type/Mfg i" 1 Capacity No. Compartments ' <br /> PKG. TREATMENT PLT. 0 Method of Disposal f n <br /> # ''Distance to nearest: Well Foundation Property Line <br /> VJ <br /> LEACHING UNE C! No. b Length of lines s.•- Total length/size ' <br /> FILTER BED G7 Distance to nearest: Well Foundation Property Line <br /> b f <br /> SEEPAGE PITS I I Depth Size Number <br /> F <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS q <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 issuedj shell not <br /> employ any person in such manner as to become subject to workmen's compensation laws of"Califorh a"'"Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shill employ persons subject to workmain's compensa- <br /> tion laws of Califor ' <br /> E <br />€ <br /> The a e 11 for altguired lnspgctions. Complete drawing on ores si I. � <br /> Signed X1.42% 1j1%,4111` Titl Date: <br /> R EPARTMENT U NLY <br /> Application Accepted by - &V-CNK1 ste <br /> PitGrout nopection by Date Fino Inspection b Dat' <br /> Additional Comments: <br /> Appl a t all copies SalJoaquin County Public Health Services <br /> .� e ur --es to: . <br /> Environmental Health Permit/services Q. Oy /9 <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201f��'O <br /> INFO AMOUNT DUE AMOUNT REMITTED Cy/CASH RECEIVED BY DATE PERMIT'N��O. i <br /> . EH14-24I#EV.kin51 -W �1DD ,Ov K to Lv—s IG_- 1,Z -`y / <br /> EH t�•7s V <br />