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' APPLICATION FOR PERMIT <br /> k SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERM11 EXPIRES 1 VEAR FRQI[ DATE ISSUED <br /> (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 <br /> application is mode in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations <br /> Joaquin County Public Health S ice . of San <br /> Jab Address L 6 .1 ,City Lot Size/Acreage GcJ' t�fr�l� <br /> � r <br /> 'owner's Name yi,. <br /> 's 2A 3 <br /> h Address Phone <br /> Contractor roes I / t, " 2 <br /> License No. n Phone !; <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Mlonitoiring Well O <br /> DISTANCE TO NEAREST: SEPTIC TAMC SEWER LINES D SAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTURE WE OTHER WELL . PITS/SUMPS <br /> INTENDED USE TYPE--OF—WELL—PROBLEM PROBLEM AREA CONSTR 10 SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. ell Ex ovation pia. o}Well Casing a <br /> C7 Domestic /Private ❑ Gravel PackL7 Tracy ofICasin —j . ' <br /> Il Public 1-1 Other ` 'f •F1 Delta Depth of Gr t Seal. ,€ Specifications ; I <br /> t Type of Grout <br /> I I irrigation �,Apprax. pepth I I Eastern Surface,Se Installed by <br /> Repair Work Done (3 Typekof Pump H.P. State`Work Done <br /> We"Destruction ❑ Well Diameter t Sealing Material Depth <br /> Depth Filler Material & Depth "f J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 16f REPAIR/ADDITION 1 I DESTRUCTION I I 7—No septic system permitted it p{tblic sewer is a <br /> t <br /> available within 200 feet,}' <br /> Installation will serve: Residence 1iComrnercial Other i <br /> Nunl of living units: Number of bedrooms_ ' <br /> Character of&A to a depth of 3 toot: f Water table depth l <br /> SEPTIC TANK. O Type/�Mfg ` '�' Ca cit <br /> Pa y No. Compartments R <br /> PKG. TREATMENT PLT.O <br /> ...� ;.. Method of Di I ' <br /> Distanca,to nearest: Well ) Foundation Property Line <br /> LEACHING LIME Cl No: 8 Liength of linea <br /> Totallength/aiza' <br /> FILTER BED Lp Distance to nearest : Weil Foundation Property Line +r! 1r <br /> r <br /> SEEPAGE PITS I I 04pth Z Size., <br /> SUMPS CI �D unto to t: Well Foundation Pro # <br /> DISPOSAL PONDS� �p ` Property Lim j <br /> e � 1 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinanceaJstate laws, and <br /> rules and!regulstions Of the San Joaquin County e <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the <br /> em lo ori performance of the work for which this permit is issued, !shall not <br /> P Y Y psnsan in such manner as to become subject to workman's compensation laws of California."Cont`racior'a hiring or sub-contracting signature <br /> certifies the following:,"I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Calif_omli." ' <br /> / . <br /> Thea � <br /> pplieant st call for of fired ins pe'tions. Complete drawing on reverse side. ` p <br /> Signed r >' ,s <br /> Title: ` l <br /> ^r�r�$" � Data: <br /> 13 <br /> § FOR DEPARTMENT USE ONLY t <br /> Applicatbn Accep tod by — �- <br /> ate Area �`/ <br /> fiat r Grout Inspection by Date Final lrupection y <br /> r Date / <br /> ddhionali Commons:� a- � <br /> Applicant =.,+Return all-copies to: San Joaquin County Public Health Services t <br /> ` Environmental Health Permit/Services <br /> Joaquln_,_P.0 Box 2009, Sthn,,CA 95201 <br /> FEE <br /> INFO` AMOUNT DtJE r— AMOUNT REMITTED CK <br /> CASH RECEIVED 9Y DATE PERMIT No, <br /> em f3•as 111EY.t/n pt A' 1 I Ve <br /> EH,..� !" { 1 7 . �3�d <br />