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x APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> 445 N SAN JOAQDIN, PHONE (209)4fi8-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ` <br /> PERMIT EXPIRES 1, YEAR FRQM D TE ISSRIM <br /> (Complete in Triplicate) <br /> .4 <br /> APPlication is hereby made.t:o San Joaquin County for ar <br /> application is made in c permit to construct and/or install.the work herein described. This <br /> ampliance with San Joaquin County Ordinance Ho. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I � --- <br /> Job AddressL City Te7ek Lot Size/Acreage <br /> r <br /> Owner's Name Address Oa�._2_ <br /> a2 t,4 <br /> Phone& <br /> Contractor/ r H "7g3dress icense fVo Phone Z-, <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST; SEPTIC TANK �Q�� ` SEWER LINES _6242-f— DISPOSAL FLD�p.� PROP, IL NE <br /> FOUNDATION AGRICULTURE WELL OTHER WELD PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom C3 Manteca .Dia. of Well Excavatio ` <br /> J Dia. of Well Casing <br /> �pmestic/Private kof-(sraval Pack ❑ Tracy .Type of Casing_ Specifications (} <br /> I"I Public Cl Other ` {'1 Delta Depth of Grout Seal Type o Grout `[�1 <br /> ! I Irrigation / 7�7j-Approx, Depth [ I Eastern Surface Saul Installed by _ ' r (�� <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth ]Tiller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOITION I 1 DESTRUCTION I i INo septic system permitted if public sewer is <br /> .available within 200 feet,) <br /> Installation will'servC- 'Residence,"'°_C6rrimarcial^Other <br /> Number of living unitti Number of bedrooms <br /> Character of soft to a # <br /> depth of 3 feet: Water table depth <br /> SEPTIC TANK. E] Type/M/g Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal „ <br /> Distance to nearest: Well Foundation property Lina _ <br /> LEACHING LINE ❑ No. b Length of linea Total length/size <br /> FILTER BED 0 Distance to nearest: Wolf <br /> Foundation _ Property Line , <br /> f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Welt Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 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 tiecome subiset to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> a ifLmw of the f�lr o "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 <br /> The applicant must calf for alt required inspections. Complete drawing on reverse side. t <br /> < e <br /> Signed <br /> C Title: �--� i-- <br /> - Date: i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pito Grout nspectlon b � a Fyt+l In by " <br /> Dara ; <br /> AddHio Comments: <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 95201 r i►•d <br /> J(C 1�9 U IEEE AMOUNT DVE AMOUNT REMITTED CK <br /> 3 RECEIVED BY DATE� PERMIT'N0. ' <br />. EH 1124 iRtY.riRsr <br /> EH i�•�a <br />