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' APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERld T EXPIRES 1 YEAR FROM_ DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Skw Joaquin County for a permit to construct and/or install the work herein de crib <br /> application Is ms►de in compliance vith San Joaquin County Ordinance No. 51+9 and 1862 and the Runes and Regulations of San ed. This <br /> Joaquin County�Public Health Services. �- <br /> Job Address 7zr G/� r City - O Lot Size/Acreage <br /> Owner's Name AA a�t/TiT/Gf Address f&ffc, Phone zc71,!r-22r <br /> ContractorPe 1 �/f'di* .tae. Address/ d Yff"V* aE, �tZ���6 <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR C1 OTHER ❑ Monitoring Well <br /> Ejl- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE c <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing___ C Specifications <br /> l'1 Public [I Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ZVApprox. Depth I I 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 A Depth <br /> Depth filler Material Ile Depth (1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I FIE <br /> PAIRlADDlTlON I I DESTRUCTION I I (No stem Septic s <br /> p y permitted it public sewer is j <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms r�(, <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, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. b Length of lines Total length/size <br /> FILTER BED ❑ 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 ❑ <br /> I heraby 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 candies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson 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"Itomla," <br /> The applicantimpst call for all required inspections. Complete drawing on reverse side. <br /> Signed Title' Date: - g�- <br /> FOR DEPARTMENT USE ONLY Q C�' 5T­217. e x:> <br /> Application Accepted by Date r �' 1 Area Uri <br /> Pit or Grout Inspection by Date •02� - Final Inspection by Date/ r^ rt L <br /> Additional Commants: C{ &(q,3 fhc-t L Me11- rZ <br /> Applicant - Return all copies to: San joaquil County Public Health Services IA1�141 <br /> Environmental Health Permit/Services �V�Y�1b} <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO RECEIVED BY CASH DATE PERMI7'NO. <br />. EN 13.2 uEV.sinal �� BY' <br /> EN,�.,, - 4�D q-,2 -`�li Z-323 <br />