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APPLICATION FOR PERMIT ` , <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Now <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT EM,j,R9g„.1YEAR PROII[_DATE �jSHUEO `N\1_3 U <br /> (Complete in Triplicate) Y <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 /> XJob Address � ��/��� City k/ <br /> Lot Size/Acreage g9 x I� <br /> N< <br /> Kwn@('& <br /> 4 <br /> Name Address Phonaw ` <br /> 1_/ Sim <br /> 1*N& <br /> ontractor r Address _ � License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT (•.l DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O monitoring Well <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 PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern Surface Sedl installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material E Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION Ll DESTRUCTION INo septic system permitted if public sewer is <br /> vailable within 200 feat.l <br /> Installation will serve: Residence Commercial,.___, Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �{ <br /> SEPTiC TANK. ❑ Type/M c y No. Compartments <br /> PKG. TREATMENT PLT. ❑ P F7 Method of Disposal <br /> Dist�lnee tokq\ <br /> yi <br /> e!I Foundation Property Line <br /> LEACHING LINE ❑ No. & Length Qp�fppli��nl�esnUl Total length/size <br /> FILTER BED n DistanWQ��afW.,9 C' I F undation A Property Line <br /> r• _r h DV1SI()n <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation 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 cavity 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 cenify 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 /> T applicant all for req u ctions. Complete drawing o�erse side. <br /> fined. Title: _ I�nP r, „„ .............. Date: <br /> OR DEPARTMENT USIE ONLY <br /> Application Accepted by DatetZr Lt _9 4 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant — Return 911 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 <br /> FFE MOUNT DUE AMOUNT REMITTED CASH RECEIVEO BY DATE PERMIT'NO. <br /> • fH 13.24 IREv.I I K 51 /. J.? ala <br /> @H-ale <br />