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APPLICATION FOR PERMIT <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, STOCgTON, CA 95201 ` ,IST/f V� v6 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7 l7 <br /> (Complete in Triplicate) <br /> Application in hereby rade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotmpliance with San Joaquin County Ordinance No. 51+9 and 1 62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. rr <br /> Job Address + 1 J C i City Lot Size/Acreage <br /> Owner's Name d`' '�/` Address Phone / -� v <br /> L <br /> Contractor Address a&�_License No. Phone /q ,7 022 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring well C]DISTANCE TO NEAREST. SEPTIC TANK SEWER LIN POSAL MLD. PROP. LINE <br /> FOUNDATION AGRICULTUS WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO TR ION SPECIFICATIONS <br /> ' C�Industrial . '—;--Q-.Open_ Bottom ❑ Manteca Die. all Excavation Dia. of Well Casing <br /> N Domestic/Private ❑ Gravel Pack ❑ Tracy_ of acing Specifications <br /> 11 Public 1:1 Other ft Delta Depth of out Seal Type of Grout <br /> -I-I-Ifrigation — .YDS Approx. Depth 1 I Eastern" Surface Sea stalled by .J <br /> Repair Work Done U Type of.Purrip _ .P. State Work Done_ <br /> Well Destruction _,, ❑ Well,Diameter t Sealing Material i Depth — <br /> Depth . _ Filler.Material.i ptahg"X; { <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I -REPAIR/ADDITION l DES TRUCTi N.I_i,.1No-septic_sysrem permitted if public sewer is �} <br /> �,,,�va;ViIN11200 <br /> 1 tJInstallation will serve: Residef -nceCommercial_—Other <br /> s..• f � <br /> 1 Number of living units: Numberof bedrooms <br /> Character ofsoil to a depth of 3 feet: Water table depth <br /> f SEPTIC TANK. ❑ Type/Mfg " X Capacity_.. No. Compartments <br /> r PKG. TREATMENT PLT.❑ + � Method of D' icer 1 <br /> Distance to nearest: Well•Foundation (j- 'Property Lins s / <br /> 1, <br /># LEACHING LINE 0 No. 6 Length of lines N_ . Tojal length/size I - <br /> r FILTER BED Cl Distance to nearest: Well Foundation � Property Lina /�T <br /> 6 <br /> t SEEPAGE PITS 11 Depth Sire N mber _ <br />} SUMPS LI Distance to nst: Well Z0 0 ZFoundation Property Line�� d <br /> DISPOSAL PONDS 1 ❑ <br /> I hereby certify that if 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 Sen 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, 1 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 /> tion laws of California."` <br /> The applicanttrcafg or all r ired ins ctions. Complete drawing on reverse side. <br /> p S '� <br /> f Signed 1 Title: ��l—Y W r Date: � f <br /> f � R PARTMENT USE ONLY <br /> ication Accepted by 141 Date I Area ' <br /> P' t Inspection by Date Final In trios by L Date '7 <br /> d ' nal Comments: <br /> tae S 3 <br /> Applicant - Return all copies to: San Joaquin County Pub is Health Services <br />} Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNTREMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> . EM 151 (REV.timSl5;L9 1 : 0 !-1 �.J ..� / <br /> i <br /> i <br />