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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 I DU <br /> (209) 468-3447 <br /> R kROM 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 made in cotwliance with San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address , LA, l^I - CityCJ % Trot Size/Acreage <br /> Owner's Name ;��-V�/ i �A _ Address -ELI-09q. C1 Phone <br /> U t Address o' ,EC3� q� �'� I License No Phone - 1 <br /> • <br /> Contractor •S <br /> TYPE OF WELL/PUMP: KM WELL ❑ WELL REPLACEMENTX DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION{ SYSTEM REPAIR I-] OTHER ❑ Monitoring Well E� <br /> DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECiFICATI,O IS <br /> r' Industrial 1>0 Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> gDomestic/Private ❑ Gravel Pack 0 Tracy Type of CasingSpecifications <br /> M Public 1:7 01�tor ❑ Delta Depth of Grout Seal t Tµpa o Grout " <br /> M Irfioation ��1� Approx. Depth Eastern rfaee Saul Installed by-1 r h CA <br /> Repair Work Done U Type of Pump, H.P. State Wo!� e _ <br /> Well Destruction Walt Diameter Sealing Material & Depth f9- ' D 92A 1.! a T &qok 0 <br /> Oepth+ Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 11 DESTRUCTION CI (No septic system permitted if public sewer is <br /> available within 200 loot.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <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.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size .T -Number t <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I <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 cenifies 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 workmen's compensation laws of Califo(nia," 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 California." <br /> Thd applicant mus call f "ll req u.red t spections. Complete drawing on reverse slid <br /> Signed Title: Date: <br /> 93 <br /> OR EPARTMENT USE ONLY <br /> F <br /> CFO <br /> Application Accepted by M Date Area 2 <br /> Pit or Grout Ina y Date J_.1Zzr� <br /> Inspection b '� []ate � fir' Final Inspection by <br /> i <br /> Additional Comments: - 3 <br /> Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STUCKTON, CA 95201 <br /> j <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REWrTED GASB RECEIVED BY DATE PERMIT'N0, <br /> L.tJ <br /> I <br /> . EH 1 .24IREV.w/n51 ti <br /> EH:..m 3 tom 91 i' 9 L) 2- to <br />