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0 <br /> APPLICATION FOR PERMIT <br /> :F. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONIEENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009; STOCKTON, CA 95201 <br /> f <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cowiiance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Jb Address C z� G�' City Lot Size/Acreage <br /> Owner's Name <br /> 7ft4rA( I/- oY�7 Address R 66 �j Sypi to/0 . . /tit Phone <br /> Contractor 4&aV&y ' SOA' Address 10004 �Lt1 d der License No.y�yMZ1Z_Phone <br /> TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C] Out of Service Well 0 <br /> PUMPi�INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well.,L <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> I� FOUNDATION AGRICULTURE WELL 'OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> �7 <br /> Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> l}'l Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material Ji Depth <br /> Mller Materiel i Depth r} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION i I DESTRUCTION l I (Noseptic system permitted if public sewer is <br /> �� �I available within 200 feet.) z <br /> ill,Installation will serve: Residence_ Commercial____ Other J obl��ot7C' r <br /> t <br /> Number of living units: _. I�.Number of bedrooms T--+--� <br /> ,S`Character of Boll to a depth of 3 feet: 1_1i4yV 14iR1y --- Water table depth 3a <br /> .,'SEPTIC TANK. �1 Type/Mfg 2ke 69f� �6 Capacity !�'aD- "No:Compartments <br /> -'' PKG. TREATMENT PLT.❑ 1 > ]]] <br /> Method of Disposal <br /> Distance to nearest: Well O Foundation .' ~14 Property Liney <br /> LEACHING LINE ❑ NoM'b Length of lines Total length/sire <br /> "FILTER BED 0 Distance to nearest: Well Foundation 4 Property Line ` <br /> r <br /> P.. <br /> SEEPAGE PITS I 1 Depth Size— !�r 1 Number 4 <br /> .SUMPS kf Diayunce to nearest: Well 2JO0 Foundation �y� Property Line <br /> pISPOSAL PONDS ❑ �I ' <br /> I hereby certify 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 eenifies the following: "i certify that in the performance of the work for which this permit is issued, I shall not <br /> f alilornia." Contractor's hiring or sub-contracting nature <br /> employ any person in such manner as to become subject to workman's compensation laws o C g g mg <br /> certifies the following:"I tastily 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 /> The applicant m t call for required inspections. Complete drawing on reverse side. <br /> .139- <br /> Signod Title: Date: <br /> FOR PARTONLY. <br /> Application Accepted by Date Ar <br /> �3 <br /> Pit or Grout Inspaction by Date Final Inspection bvoaDatt� <br /> Additional�a}trya O r �� / a /rG�ldEGt C^.7fw <br /> •}'c✓i <br /> r Applicant - He, a l copies to: San Joaquin County Public Health Services � ��/����� <br /> 1 Environmental Health Permit/Services "�y <br /> 445 N San Joaquin, O Box 2009, Stkn, CA 95201 �e�f� FD =✓� ��� <br /> FEE AMO NT DUE AMOUNT REMITTED el K ECEIVED 9Y ATE PERMIT'NO. <br /> INFO <br /> . EN 1324 IAEV.It 5) � <br /> I EN i1.1a <br />