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b <br /> p c APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES . <br /> IINVIRONWsI1TTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 � <br /> I � P O BOX 2009, STOCKTON, CA 95201 <br /> f <br /> PERId T-EgPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made,to Sam Joaquin County for a permit to construct and/or install the vont 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 /> Job Address /ywG ?.77! g LK 57pw+~� City L47WRGP Lot Size/Acreage AC <br /> Owner's Name/' 4r- Q (A9A1 Address j0-49- A9OX SSC lLnAl Phone 5673 xl <br /> / 1 <br /> Contractor Address _ <br /> License rvo. Lu?D1> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ a146ktciring Well 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRO41AR9 �� ~ ! <br /> FOUNDATION L� AGRICULTURE WELL OTHER WELL PITS/SUMPS o'g <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST L)CTIO1 SPECIFICATIONS i <br /> n Industrial ❑ Open Bottom ❑ Manteca ._. Dia.,of'lWell'Excavation Dia. of Well Casing <br /> C7 Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications � k <br /> I') Public C7 Other ! n Delta Depth of Grout Seal Type of Grout <br /> 1 1 Irrigation —.Approx. Depth II Eastern Surface'Si64 - tailed by <br /> Repair Work Done ❑ Type of Pump { H.P. ' State Work Done - <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth 7 biller Material i Depth } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/AODITIQN I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial - Other it. <br /> Number of living units: Number of bedrooms <br /> Character of Boll to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg '� t�``' ' <br /> Capacity No. Compartments <br /> - <br /> t� <br /> PKG. TREATMENT PLT.❑ t !! Method of Disposal <br /> Distance to nearest: Well Foundation T Property Line <br /> LEACHING LINE CI No. b Length of:linea _ _ Total_4ength/sire I <br /> FILTER BED 0 Distance to nearest. Well T Foundation Property Line <br /> i <br /> SEEPAGE PITS I l Depth ' size Number <br /> SUMPS LI Distshce to neat: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this applicmontand that the work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> rules and regulations of the San Joaquin Cotanty <br /> Home owner or licensed agent's signafure,c-inif4a 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 td become suoiect to workman's compensation laws of California,".Contractor's hiring or sub-contracting signsture <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 compenss- <br /> tion laws of Call I ; <br /> The applicm call for ed inspections. Complete drawing op adverse side <br /> Signed Title: _-�� _RES/O��t/� � Date' _15-3-`j3 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date _�;- res 1 - S <br /> Ph or Grant Inspection by Date Final Inspection Date <br /> Additional Comments: <br /> Applicant - Return all copies to: $an Joaquin County Public Health Services` <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, $tkn, CA 95201 <br /> FEE <br /> CK 0 <br /> INFO AM7,NT <br /> DUE AMOUNT REMITTED CASH EIVED BY 0 TE PERMIT•NO, <br /> . EN 13-24 IAEy.it St d r <br /> EN U-2A <br />