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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONI[SNTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROIIi DATE I S QED <br /> (Complete in Triplicate) <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joe In County PublicHealth Service <br /> Job Address _ :f®//Z City Lot Size/Acreage paw <br /> Owner's Name _t-12 I jig aZ002 Address Phone <br /> Contractor &6aAddress License Naa-� Phon - <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENC�5� DESTRUCTiO �'Wt of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAI ❑ OTHER ❑ Monitoring Well C3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -- _ DISPOSAL FLD. PROP. LINE ic '"_— <br /> FOUNDATION AGRICULTURE WELL OTHER WELLf PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin L <br /> >4omestic/Private 'Gravel Pack7 / ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public it Other n S fl Delta Depth of Grout Seal pe of Grout <br /> el <br /> I I Irr" <br /> rp t� <br /> anon Approx. Depth l I Eastern Surface Seal Installed by va <br /> Repair Work Done 0 Type of Pump H.P. State Work Oone_ <br /> Well Destruction 35< Well Diameter Sealing Material i Depth <br /> Depth i` 1151 s Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I t INo septic system permitted if public sewer is <br /> available within 200 leei.l <br /> Installation will serve: Residence-__- Commercial_ Other <br /> Number of living units: Number of bedrooms_ter <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. b Length of linea Total length/size <br /> FILTER BED. 0 Distance to nearest: Wolf Foundation Property Line o <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cenify 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 foNowing: "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 Celifomia." <br /> The applicant inust call for all required ingwptions. Complete drawing on r versa side. <br /> � /%"/.f h <br /> Signed X I If Jr. ,,.... Title: — >��-- _ Date'/�� ? �— <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area / <br /> Pit o Gout paction by !! ✓ Data I h I 6 I A 1,i..1 Inspection by <br /> Addltbnsl Comments: d l f(1 0" l C <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 85201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY DATE PERMIT'No. <br /> • EM 1521 IRFV.1inS1 (- <br /> EH t.sa fD� ��b� !o- �- 'L qz� <br />