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APPLICATION FOR PERHI- <br /> SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> r 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 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. 51+9 and 1$62 and the Rules and Regulations of San- <br /> Joaquin County Public Health Services. <br /> Job Address -1-1) 17P Cit Lot Size/Acreage ^� <br /> q <br /> 4 j Phane <br /> ' Owner's Name d s <br /> i I f <br /> Contractor Address License No. / 03 hone /Q Ll <br /> TYPE Of ELL/PUMP: N WELL O WELL REPLACEMENT CI DESTRUCTION Pftt of 'Service Well L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring 11 n <br /> DISTANCE TON EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMP P <br /> INTENDED USE ':: <br /> F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial ttom ❑ Manteca Dia. of Well Excavation Dia. all Casing V' <br /> (1 Domestic/Private ack ❑ Tracy Type of Casing_ pecifications <br /> Ili <br /> l'I Public n Delta Depth of Grout Seal - Type of Grout <br /> 1 1 Irrigation ..� Approx. De I I Eastern Surface Seal Installed by <br /> } Repair Work pone ❑ Type of Pump H.P. State rk Done_. <br /> Wall Destruction O Well Diameter Sealing Naterial i Depth <br /> Depth - tier Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/A ITI CTIO INo septic system permitted if public sewer is <br /> able within 200 feet.) _ <br /> ff Installation will serve: Residence Commercial Other <br /> ' Number of living units: Number of bedrooms <br /> 1 Character of anil to a depth of 3 feet: ) m Ware t <br /> SEPTIC TANK. ❑ Type/Mfg 1 h "pIC *�I rtments <br /> F PKG. TREATMENT PLT.0 ! y ,+y�rQr A etj?(d e11�of$ oral vs <br /> Distance to nearest: W Foundation m� L'ihtfp � <br /> LEACHING LINE D No. b Length of Ii Total length • e <br /> FILTER BED p Distance to'' at: - _. Well - .Foundation Property 'no <br /> 1 <br /> SEEPAGE PITS 11 Dep "Size Number <br /> t SUMPS LI tstance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I holve prepared this application and that the work will be done in accordance with San Joaquin county dinances, state laws, and <br /> rules and regulations f the San Joaquin County <br /> f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perm is issued, I shall not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California,"Contractors hiring or sub-co ratting 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 /> I The app" ant r uir ' spa tions. Com late awing on r verse side. <br /> i Signed Title: Lq�� - Date: <br /> OR DEPARTMENT USE ONLY 1i r G} <br /> Application Accepted by Date ` �?"!L Area 24 —5 <br /> Pit or Grout Inspection by 1 Date Final Inspection by Data <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 /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> CV if RECEIVED BY DATE ^ PERMIT'NO//. <br /> a EH 17.4 tttNr-1/M 61 Sb { �„� �_ 1 ?`•''j <br /> EM li•a! G•7�f r J I <br />