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APPLICATION FOR PERMIT i <br /> I <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 MIRES 1 YEAR FR9M• DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby glade to San Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is rade in eow�llance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County blic He th Sery ea. <br /> Job Address t tit City 51 Acreage <br /> LmpezAwQer's Name � — Address D^ I. Phone ... <br /> Y!o, Vo, f '" L A r R [1f� e 3f_3 i <br /> ai,4;+cense N Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT F.1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM'REPAIR ❑ OTHER ❑ 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 /> C7 1 dustno C3Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications ` <br /> I'3 Public !7'Other—'` "° ^ f 1'Delta ^ '^!Depth of-Grout-Seat Typo-of Grout-- <br /> I .I Irrigation Approx. De th I I Eastern urfacs Seal Installed by I <br /> Repair Work Done LJ Type of Pump H.P. State Work D �. <br /> Well Destruction ❑ Well Diamet r Sealing Mate ial i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public Bawer is i <br /> available within 200 feet.) <br /> Installation will some: Residence_ Commercial— Other i <br /> Number of living units: °v Number of bedrooms i <br /> I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method-of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines '• Total length/size <br /> FILTER BED 0 Distance to nearest. Well 6 Foundation .Property Line f <br /> SEEPAGE PITS 11 Depth r`•„`wSiza Number` <br /> SUMPS Ll Distance to nearest: Well Foundation Pr000rty.Line� <br /> DISPOSAL PONDS ❑ J <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 4 <br /> rules and regulations of the San Joaquin County ---. f <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 shell not <br /> employ any person in such manner as to become subject to workmen's compensation laws of California..',;Contractor_s.hiting_orsub•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 /> tion Is of C 'fomla." ; ? ; .✓ r .� <br /> The appllc st call ed in tions. Complete drawing on r as rid . <br /> t <br /> S, Title: Data: <br /> �FD�EPARTMENT USI: ONLY � p, <br /> Application Accepted by Date 1 a <br /> Pk or Grout Inspection by Date Final lnspaction b Datrf� <br /> Additional Comments: ' <br /> I <br /> Applicant - Return all copies to: San Joaquin County Public Health Services I <br /> Environmental Health Permit/Services , <br /> 445 N San Joaquin, .P 0 Box-2009, Stkn,-CA 95201 <br /> fINFO <br /> �FEE AMOUNT DUE AMOUNT REMITTED UAMOT RECEIVED BY DATE PERMIT N0. <br /> . EH 1 <br /> 3-24IREV.s,N S1 / R :SS.ie <br /> EH li•20 ✓ <br /> 1 <br />