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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL 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 made to Sats Joaquin County for a permit to construct and/or instar the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulwtions of San <br /> Joaquin County Public Health Services. ^ �y <br /> / Job Address `7-70tW. �g ----- /Safi. _ City Lot Size/Acreage <br /> \\ 811 Owner's Name kl r��4t Z �o,�� --- Address `0_ /" leL Phon es <br /> Contractor CLLZa_,� b Address 0 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION out <br /> of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHE ❑ 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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> CI Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth 11 Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. ork Do e_ <br /> ��.WellDestruction ❑ Well Diameter Sealing llfaterial i Dcpth !-Y�= for Q <br /> DepthWZ� biller Material i Depth <br /> TYPE OIrS-EPTIC WOR ALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms (� <br /> Character of wit to a depth of 3 feef_ 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 UNE D No. S Length of linea Total length/size <br /> FILTER BED ❑ Distance to nearest. Well IyFoundation Property Line <br /> a <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll 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 W done in accordance with San Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin county <br /> Horne owner or licensed agent'ssignature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject tb workman's compensation laws of Cefifornia."Contractor's hiring or subcontracting 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 /> Wn laws of Caldor <br /> The applicant at call for al equir i pactinns. Complete drawing at4l5p <br /> rseside. <br /> Signed Title: _ Date- ! L <br /> 4 � <br /> F USE ONLY <br /> Application Accepted by Date �� ✓ e <br /> Pit or Grout Inspection by Date Final Inspection b Dated S� - � <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br />` 445 N San Joaquin, P o Box 2009, Stkn, CA 95201 <br /> E{I <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED Ck L-A SH RECEIVED BY DATE PERMIT'ND. <br /> Ir �1 Q�j <br /> . EN 13-21IAEV. 51 <br /> 14-20Zd W o ll,d <br /> EH J Lam' <br /> 1 <br />