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APPLICATION FOR PERMIT <br /> ,i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ✓� P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> i PF.RiII T RXPT RES_ 1 -YEAR—PM DATE I SSUFD <br /> al (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 i <br /> application is made in compliance with San Joaquin County Ordinance No. '549 and 1862 and the Rules-and Regulations of San <br /> Joaquin Colony Public Health Services. <br /> 1tR . <br /> Job Address 0 City Lot Size/Acreage <br /> y_, �--� <br /> Owner's Name Address Phone <br /> Contractor I A PALQWStddress' C-3-56 tk) +cense Na. Phone <br /> TYPE OF WELL/PUMP:,: roc NEW.WELL ❑ WELLIREP'LACEMENT 71 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER-LINES DISPOSAL FLD, PROP. UNE <br /> FOUNDATION AGRICULTURE-WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p <br /> 171 Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1.1 <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public Cl Other\ ! ❑ Delta Deplth�rout Seat Type of Grout , <br /> EJ irrigation ._._,Appro> pth 0 Eastern Surface_Sob Installed by II <br /> Repair Work Done U Type of,Pump H.P. ` State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INS,LALLATION__f_A,.EPAIRlADD17.ION,IIOES7RUC710N G (No septic sys[em-permitted'i( puplic`svv ei is <br /> available within 200 feet,) <br /> 'Installation will serve: Residence�mmsrciit OISZ <br /> Number of living units: _L_ Number- f bed��s~ i <br /> Character of wit to a depth of 3 feet: a Water table depth <br /> SEPTIC TANK. ❑ Type/MfgChAJJ!l-F�jiE� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ', / Method of <br /> Dis"pjosa). <br /> Distance to hearer Well Foundation Property Lin"VI <br /> __/ i <br /> LEACHING LINE 0---Nt3-& Length'of lines LL� 'T a Toial length/size <br /> FILTER BED n Distance to nearest: W I ';Faun tion , Property Line <br /> SEEPAGE PITS �pth• ) Sire Number <br /> SUMPS <br /> qL,L4i nce to nearest: Well Foundation L Property Line <br /> DISPOSAL PONDS ❑ <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 San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I comity 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 eompenss- <br /> a of Californla." } <br /> 'he applica t call or 11 r�vwe Is draw ng, versessi r <br /> Sign Date: ! <br /> F EPARTMENT USE ONLY < <br /> Application Accepted by � ry ,- _ �. - Data;—1 U�_' � -A�rea_ ` `�•� <br /> Pit or Grout Inspection by Date Final inspection by S� c t J Date :2 <br /> Additional Comments: <br /> r _ , <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. <br /> „�,^,.,.��_,. .�. .- . -:---EN.Y.IRONJdENTAL-NEALTH�b3V3$I43N=PERMIT/SERVI•CE3 - <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 <br /> .-'.. ` . r <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> f� <br /> + EM I3•24 119EV,i i sr <br /> 11 <br /> EH'.4.2a <br /> C. <br /> ,f <br />