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a <br /> �I APPLICATION FOR PERMIT <br /> i7 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> a 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, .STOCKTON, CA 95201. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health 8e <br /> Job Address ces. <br /> 3,3 <br /> Cit Lot Size/Acreage <br /> Owner's Name (2 Jo Zj Address F Phone <br /> Conlractor -i Address9 License No.Z�m Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNOATIbN AGRICULTURE WELL OTHER WELL PITS7SUMP5 <br /> INTENDED USE TYPE OF WELL PR LEM AREA CONSTRU T C ! Aj,'j'H SERV <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca jg % A�C�LW SCWof Well Casing <br /> Cl Domestic IPrlvale i '❑ Gravel Pack ❑ Tracy TV,Casing_ 1 �cifications <br /> I'1 Public. I-1 Other . F1 Delta_,- Dept ' + e-,,a - jYPa o1 Grout <br /> F <br /> 13 Irrigation -j ,� .!�Approx. DI I E stern Surface 5eai installed by <br /> Repair Work Done' U epth Type of Pump _ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material_& -Depth'% ' <br /> TYPE OF,SEPTIC WORK; NEW INSTALLATION I I REPAMIADDITION 1 RUCTION I I INo septic system permitted it public sewer is <br /> 11 �k i available within 200 feet.) <br /> Installafion will serve: R Wenee Commercial Other <br /> Number of living unite x Number of bed r ms J <br /> Character-of soil to a depth W-3 feat: Water table depth <br /> SEPTIC TANK.` ❑ Type/Mfg c Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ .Method of Disposal <br /> t ` <br /> ­--Distance-to 7Distance-to nearest: Well - Foundation--- --- Property Line <br /> I <br /> LEACHING LINE o. fir Length of lines T tel length/size <br /> FILTER BED O Distance to nearest: Welles Foundation Property Line <br /> h SEEPAGE PITS IL,�pth Siza` Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f Iv�/ <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 /> l rules and-regulations of the San�Jbiquln downy <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 /> f 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 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 /> tioQ.. . omia." -Ths tioCom to drawing on ae sidSiTitled Date: <br /> l I _ <br /> R ARTMENT USE ONLY <br /> i22 Date �1 ! Area <br /> Application Accepted by �/ <br /> Pit or Grout Impaction by # Date - Final Inspen by Date // 7 <br /> Addhiotul Comments: <br /> Applicant - Return all copies to; San Joaquin County Public Health Services "' <br /> Environrnental,Health Permit/Services <br /> k� 445.N San Joaquin, P O B 2009, Stkn, CA 95201 <br /> r IF 0 AMOU T DUE AMOUNT REMITTED ICK E E <br /> RIVED BY DATE PERMIT N0. <br /> . EH 13.7411tEV.rises A 1 <br /> EH 14-Ie <br /> t <br />