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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT .EXPIRES 1 YEAR 1IROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby sends to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> XobAddressSeca�[on City T-Ln Lot Size/Acreage <br /> e 9 a'ry 7� <br /> Owner's Name �Or C. teUIAs — Address <br /> oniractor ' _ ___ ____ Address License No, Phone <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION A Out of Service Well 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> U Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 1-1 Other 0 Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth © Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> IDepth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JD REPAIRJAOITION M DESTRUCT NCI (No septic system permitted it public sewer is v <br /> available within 200 feet.) <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 C city No. Compartments <br /> PKG, TREATMENT PLT.C1 - Method of Disposal <br /> Distance to nearest: Well F Ind 'on Property Line <br /> LEACHING LINE L1No. 8 Length of lines Total length/ei:e <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> SEEPAGE PITS I I' Depth Sire Number <br /> SUMPS LI Distance to nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby conity 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 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- <br /> lion laws of California." <br /> The applican at call for sit required inspections. Complete drawing on reverse side. <br /> Signed ZL UW4 Title: _ .&A L MlA Date: . <br /> EPARTMENT USE ONLY <br /> Applicata Accepted by - Date �~ ` Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: $ S <br /> Applicant — Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 85201 <br /> FEE <br /> INFO AMOUNT DUE AM NT REMiTTEO CK4 IF RECEIVEO BY DATE PERMIT NO. <br /> . 16 <br /> EM 13•24 iREy.1/85) <br /> �- <br /> EN,bye V <br />