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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 <br /> (209) 468-3447 <br /> PERMIT EXPIRES 1 YEAR rROM 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 in trade in ccowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ZO <br /> 4fIra / r- Cit911� CtiVkot Size/Acreage <br /> Owner's Name &� / 1? s�C lti!�- Address/ ?'/ `, 1AMIX 1"4 A_V"ar-P, Phone <br /> Con tractor °` !11Addtess� •� a `� License Na. 16,?3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION Cl out of Service Well Cl <br /> PUMP INSTALLATION A - � SYSTEM REPAIR ❑ � OTHER ❑ Monitoring Well �Z <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP...UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL-- PITS/SUMPS -r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom © Manteca Dia, of Well Excavation Dia. of Wel! Casing <br /> S4 Domestic/Private ❑ Grayel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public CYOiher © Delta Depth of Grout Seal Type of Grout <br /> 0 lrrigation Approx. Depth C1 Eastern Surface Seal Installed by , T <br /> Repair Work Done v Type of Pump H.P. ,% State Work Done 4?yS>hJ1#41 <br /> Well Destruction O Well Diameter Sealing Material i Depth tufa{ <br /> Depth Filler Material i Depth 'e T `ate <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION CI DESTRUCTION Cl iNo septic system permitted if ptsbfiI5 sewer is <br /> available within 200 feat./ <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 C1 No. 8 Length of lines Total length/size <br /> FILTER BED 173 Distance to nearest: Well Foundation Property Line ' <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS -- -_ _ _ . _.L1 -.Distance.to nearest:_ Well -foundation - _ Property-Line <br /> DISPOSAL PONDS ❑ + <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 become sub?eci 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 /> tion laws of California," <br /> The applicant ust call for all re 'red i pections. Complete drawing on reverse side. <br /> Signed cl Title: �D'!? C,�c��" <br /> .,,..,...--•--•- _ ._ ,...�. Date: <br /> FO DEPARTMENT USE ONLY f <br /> Application Accepted by Date Area <br /> 4-1 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFOAMOUNT DOE AMOUNT REMITTED I CR RECEIVED BY DATE PERM11'NO. �U1 <br /> . E 114' 4 1REV.'in5'M [� ��� ,�I cl( <br /> EMN 7{.16 111 �+ GG <br />