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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) 468-43447aW20 - <br /> JUN I T SSP I RES 1 [ DA19 ISSUED <br /> (Complete in Triplicate) <br /> Application In hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in coetpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> ,� J c <br /> Job Address 53 A 1 [ , � ,�(` rf ( City Lot Size/Acreage <br /> Owner's Name Address __ � _6-7 Phone <br /> rattorj4�%L� f S/Address� r$�a: ��:;.a.L� c R Phone -. <br /> icense No: i - a5 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well (7 <br /> DISTANCE TO NEAREST: SEPTIC TANK " M SEWER LINES DISPOSAL FLD. PROP, LINE <br /> —F.O.UNDATION_ AGRICULTURE.WELL_ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA, -CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack r ❑-Tracy"-1—. # Type of Casing t Specifications <br /> ❑ Public !! Cl Other O Delta Depth of Grout Seal ` Type of Grout <br /> G Irrigation r —.Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth � } r Bi11er.Mitiriil i Depth <br /> TYPE OF SEPTIC WORK: NEW-INSTAL LATION,f)-,REPAIR./ADDITION- STRUCTION G INo septic system permitted if public sewer is <br /> ' available within 200 feet.) r <br /> Installation will serve: Res' once 1=-�Commercimt Other. <br /> Number of living unite: Number of bedroo�t3 E <br /> Cha►acter.of soil to a depth of 3 feel l L� A t Water ;able depth <br /> SEPTIC TANK: ❑ Type/Mfg € f Capacity f No!Compartments <br /> C7 <br /> PKG. TREATMENT PLT. �.� t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE N-­K, & Length of lines - - To�ai length /sire£ � <br /> FILTER BED n Distance to nearest: Well . Foundation s .Property Line 5 <br /> SEEPAGE PITS H--Depth f Sire .Number <br /> SUMPS LI Distance to nearest: TVVeII �Founda tia-n —Property Lina <br /> DISPOSAL PONDS ❑ ✓ �.r, <br /> I hereby certify that I hive 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;theSan 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 not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Convactor'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 lef California.'<€ ! a <br /> The applicant at callII'ra uire r ns. plate drawing on reverse aid <br /> if <br /> a+ <br /> Signed <br /> Title: Date: <br /> 5 # FO SIEONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by /` Date Final Inspection by lv y Data Z `[ <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> L 9$5 N SAN JOAQUIN, P O BOIL 2009, STOCKTON. CA 95201'; <br /> INFE OUNT DUE AMOUNT REMITTED CASH Ki RECEIVED 8Y DATE PERMIT'N0. <br /> . EH 13-24 rREV.I/Ab I , t� <br /> EH;42m t t t O� �3�'tAlff <br />