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APPLICATION FOR 'PERMIT <br /> " F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> AKNVIRONMENTAL HEALTH DIVISION <br /> P'O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 4g <br /> f PERMIT F'3CP7R$ 1 YEAR MgM DATE_I0SUED <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. Thiry <br /> 1: ' <br /> application is made in coWliance with San Joaquin County Ordinance No. 549 end 1862 and the Rules and Regulations of San <br /> Joaq%ila County^Public Health Services. <br /> rLot Size/Acreage: <br /> Job Address r �i L City ---�� <br /> V Owner's Name �� - �` b0 t.Q-1-'4_ Address s gym' Phone <br /> r ( <br /> t Contractor. i� Address License No. Phone <br /> '1 TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 5 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El . <br /> Monitoring Well l7 <br /> "" DISTANCETO NEAREST: SEPTIC TANK SEWER LINES . - DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS <br /> (D Industrial ' © Open Bottom ❑ Manteca Dia."of Well Excavation Dia, of Well Casing <br /> i U Domestic/Private Cl Gravel pack 0 Tracy ,Type of Casing Specifications <br /> r <br /> ❑ Public C7 Other ❑ Delta Depth of Grau[ Seal ,Type of Grout b <br /> }} i` CJ Initiation Approx, Depth ❑ Eastern Surface Seal Installed by <br /> • ; F F <br /> Repair' Work Dona' U Typo of Pump H.P. Stale Work Done _ <br /> Wait Destruction ❑ Well Diameter Sealing Material i Depth <br /> ` Depth Filler Materisi i Depth _ <br /> TYPE_OF ^EP..TIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION Cl IND septic system permitted if public sewer.is <br /> available within 200 feet..) <br /> . � Installation will serve: Residencg.Z Commercisf_ -.Other <br /> Number of living units: f Number,of.bedrooms -3 <br /> Character of soil to a depth of 3.feet r R'fl d Water JAk1e depth ' <br /> SEPTIC TANK Type/M g r� �y�'�r r^!'=r� - Capacity +-46 Corhpartments <br /> PKG. TREATMENT PLT.❑ ( r � Y' ' I Method of Ditipor1 <br /> Distanceto nearest: Well Fotirndatiiin�" Property Line <br /> LEACHING LINE Q-"No. & Length of lines : Total length/size C16 0- <br /> FILTER BED n Distance to nearest: Wall, dation Property Line — <br /> t � <br /> SEEPAGE PITS 11 Depth Size, L41 .—Nurpber <br /> SUMPS &00*�Distance to nearest Well =` Foundation Property Lina <br /> DISPOSAL PONDS 0 -_ <br /> I hereby comity that I have prepared this application and that the work will be done in accordance with.San Joaquin county ordinahces, state Iaws, 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 Cahlornia." 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' compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections.fComplete drawing on reverse side. <br /> 14 <br /> Signed X_f 11-li.l/fs - ---- Title: __fr✓1 r Date: ` <br /> FOR DEPARTMENT USE ONLY-, <br /> iI Arae <br /> Applic;flion Accep by - <br /> or Grout Ini"pection by Date�1�/-T/. Final Inspection byData ate <br /> A `' '47,,x.,Additionsl Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SnVICES <br /> ENIIIRONbENTAL.IiYsALTH._DIVISION.-PEftHIT/SERVICES- <br /> .--�. 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE AMOUNT DIE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE '"t PERMIT NO. <br /> INFO _ <br /> i + EN 1341'IPEV.1 <br /> EH-4 211.. <br /> z <br />