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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -e 46 <br /> AN <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 ',�� <br /> (209) 468— 3ygo <br /> *^ ? �1 v <br /> (Complete in Triplicate) �. � n <br /> Application is hereby toads to San Joaquin Count for n ' c <br /> q Y permit to construct and/or install the work herein deacY:ibedr This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulatiods o4''8an <br /> Joaquin County Public Health Services. <br /> Job Address . . f,u Pd <br /> City Lot Size/Acreage <br /> Owner'a Name Address J 14F-1a..4— Phone <br /> r Ca, $5330 <br /> Contractor Address AD 0 License No, 2Phone <br /> Sir <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 17-1 -Out C Out of Service well Cl <br /> PUMP INSTALLATION SYSTEM REPAIR A, OTHER 0 Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_7 Jndustrial ❑ Open Bottom 15 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> (Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Public 1-1 Other Specifications Delta Depth of Grout Seal Type of Grout <br /> GI trri0ation _.Approx, Depth n Eastern Surface Said Installed by V <br /> Repair Work Done Type of Pump ;H.p, fLt.cw_ _— State Work Done <br /> Well Destruction ❑ Well Diameter �x Sealing Material ii Depth G <br /> Depth t Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i) REPAIR/ADDITION L7 DESTRUCTION CI (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence_•.. Commercial Other <br /> Number of living unite: Number of bedrooms <br /> Character of soil to a dsplh of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity` No. Compartments <br /> PKG. TREATMENT PLT, 0 <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. 8 Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS i I Depth Size <br /> Number <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p Property Line , <br /> I hereby certify that I hive 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 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- i <br /> tion laws of California." a <br /> The applicant must call for all (squired.inspgctions. Complete drawing on reverse side. <br /> Signed Title: It <br /> Date: .` <br /> FOR DE RTMENT USE ONLY <br /> Application Accepted by Date 2/6 <br /> Area <br /> Pit or Grout Inspection by Datet <br /> Fina! Inspection by Date <br /> Additional Comments: r-7— <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 85201 <br /> FEE AMOUNT DUE AMOUNT AEMITTED CKT.INFO CASH RECEIVED 6Y DATE PERMIT'NO. ! <br /> 6H 13-24 JAEV, <br /> EH 1�•]a M 1l <br />