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APPLICATION FOR PERMIT �a-rc e fel' <br /> SAN JOAQUIN "COUNTY PUBLIC HEALTH SERVICES 19.0 <br /> ENVIRONI[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, ` <br /> (Complete in Triplicate) <br /> Application is hereby rade to San;Josquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliancetvith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Service 1 cV <br /> Job Address - � l/�� o b1n�dG I City 7 Lot Size/Acreage <br /> / <br /> kConIracto(/_1 <br /> ner's Name �l�F s + r f Address 3 -y Phone <br /> trclfFr[ A,_ c Address C� n ,,j, t�., �S 3 Z License No. 6���7 Phone 7 7 L <br /> TY E OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._._ <br /> INTENDED USE' -­;:::-T_YPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6 <br /> ❑ Industrial ❑ OpenBottom 0 Manteca Die. of Well Excavation Dia. of Well Casing N <br /> i_". f <br /> Cl DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type.of Casing_ Specifications (� <br /> I'1 Public 177 Other 1714Delts '• Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth l I E4rr l rn Surface Seal Installed by 1 �\ <br /> Repair Work Done, 0 Type of Pum <br /> pY H.P.. State Work Done <br /> Well Destruction` O Well Dia meteIF-> Sealing Material.•& Depth <br /> Depth / Filler Material &.Depth <br /> TYPE OF SEPTIC �WORK; NEW;INS�ALLATION'I l REPAIR/ADDITION f I DESTRUCTION No septic system permitted if public sewer is <br /> s r '; T" Ate,,; e- available within 200 feet.) <br /> Installation will serve: Residence vGommercial T Othir N� <br /> Number of living units: - Number of bedrooms N� <br /> Character of Boll to a deptWol 3,feet:-4.=�=- - �+ Water table depth <br /> SEPTIC-TANK t © .,1TypelMfg f. cj '%'Cspacity� No. Compartments <br /> PKG. TREATMENT PLT.❑ "� Method of Disposal <br /> Distance to nearest: _Well Foundation Property Line <br /> LEACHING LINE ,❑ No. 6 Length of lines ' Total iengihLs' e1 CJ <br /> FILTER BED ❑ Distance toinaaratit:" `Well Foundation Prop`e'rty,Line -�, <br /> SEEPAGE PITS 11 Depth �'+ � Sire Number _ �„•,•,_ <br /> SUMPS Ll Distance to,nearest-_Well Foundation Property Line_. 1 <br /> DISPOSAL PONDS ❑ % <br /> 1 hereby certify that 1-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 fly <br /> Horne 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 California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of thework for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> ton laws of California." <br /> The a Ica t must cal for all requ• m tions omplete drawing reverse side-P <br /> igned _ Tide: _ f-Z.L _ Date: 2 <br /> RTMENT USE ONLY 1 <br /> Application Accepted by Date Area 2 f <br /> i <br /> Pit or Grout Inspection by_ <br /> Date Final Inspection by <br /> /Data <br /> Additional Comments: 'P° - '1 e8 ZS �" <br /> Applicant - Return all copies to: San Joaquin County Public Health Services U r! } <br /> Environmental Health Permit/Services sl , fit <br /> 445 N San Joaquin, P O Box 2005, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE } AMOUNT REMITTED CA4 I RECEIVED BY DATE PERMIT'NO. <br /> • E11126tREV. <br /> EHN14E6 rres' s-'ff tD� tats pb t3 23-0-207-S <br />