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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-a44-73'� % <br /> MIT EEXPIRES 1 YFsAR FROM DATE ISHU�D_ <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. <br /> Job Address A � 1- .5ff.t6:41r'/? City ������� Lot Size/Acreage �. � <br /> ,I 'i1 I► �zdt Address / 0 Yf f 2 � /q i / r!7 Phone <br /> Owner's Name ,*40J,QN 4 4 �JZ <br /> Contractor,AJOW40a le a2clekdress`?SCO j 44,, 6RAYS"Ad License No. L Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION O Out of Service Well Cl <br /> OTHER O Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <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 /> fl Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CJ Domestic/Private Cl Gravel Pack L3 Tracy Type of Casing Specifications <br /> M Public Cl Other O Delta Depth of Grout Seal Type of Grout ^ <br /> C3 Irrigation App(ox, Depth 0 Eastern Surface Sea) Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence.—A— Commercial— Other <br /> Number of living units: --i— Number of bedrooms 3 <br /> Character of toil to a depth of 3 feet: Water table depth <br /> SEPTICUNK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> :' Total len th/size <br /> LEACHING LINE ❑ No. & Length of lines g <br /> FILTER BED C-) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth --Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 San 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 sub-contracting 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspgctions. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> elli DEP <br /> Application Accepted by <br /> Date <br /> J611-n- ea <br /> 10, <br /> Pit or Grout Inspection by Date Final Inspection by Dats <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ' ,. ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE P£RMIT'N0. <br /> INFO <br /> + EH A-M IREV. i x 5I - <br /> c� Z.79 S �Yl�- ', 1( � 1 1 -13 t <br /> EM 1�•2a <br />