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M-. <br /> APPLICATION FOR PERMIT <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 96201 <br /> (209) 468-3447 <br /> •--` PERMIT EXPIRE69 I PATE MM <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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public HealthServices. <br /> ,l <br /> Job Address Z <br /> 17 11 <br /> 75 . Sv W �cs City Gt/np Lot size/Acreage <br /> a I <br /> �!/� �T l Address M C Phone <br /> -t-V <br /> - 7 ,"0 <br /> Owner's Name i' <br /> Contractor f� 42t - Address `J nF- - —_License No .72 - Phone3� ��7 s i� <br /> TYPE OF WELL/PUMP: NEW WELL <br /> uu WELL REPLACEMENT P DESTRUCTION ❑ Out of Service well L1 i <br /> I PUMP INSTALLATIONSYSTEM REPAIR 0 OTHER O Monitor Well i7 <br /> DISTANCE TO NEAREST:_ SEPTIC TANK +- SEWER LINES DISPOSAL FLO. PROP.-LINE 3 <br /> FOUNDATION "`AGRICUL'TURE WELL OTHER WELL SPITS/SUMPS <br /> k INTENDED USE TYPE OF'WELL. PROBLEM.AREA XONSTRUCTION SPECIFICATIONS <br /> ❑ Manteca Dia. of; IWaH Excavation Dia. of Well Casing <br /> 17 Industrial O Open Bottom —yw <br /> 'Dom,}stic/Private XGraval Pack- ❑ Tracy Type of Casing Specifications <br /> ❑ Public I 1-1 Other f ❑ Delta Depth of Grout Seal 5y - Type of Grout C �A eN <br /> tJ tnipalion '3 .Approa. Depth ❑ Eastern Suroace Seal Installed by <br /> Repair'Work Done U Type of Pum fy0 H. State Work Done _.��d <br /> _ _._..�.- p � -�-.:_ w--�-----�.—•-.,-----^...—.,--y <br /> - Well Deitruction'�`T 0__Weit Diameter <br /> 1 <br /> Depth I' Piller Material Ir Depth <br />` t <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION 0 REPAIR/ADDITION Irl DESTRUCTION G (No sepiie.sYstem permitted if public sewer is ( - <br /> available within 200 feet.) `-'\ <br /> !Installation will serve: Residence-- Commercial— Other <br /> Numbl r of living units: Number of bedrooms <br /> Character of soil to a'depth of 3 feet: Water table depth <br /> SEPTIC iTANK ❑ Typi/Mfg ' Capacity No. Compartments <br /> PKG, TREATMENT PLT. C) r ' ; Method of Disposal <br /> 4 a <br /> j444 Distance to nearest: Well Foundation Property Lina <br /> r <br /> LEACHING LINE ❑ No-4 Length of linea ' i Total length/size <br /> FILTER BED n Distance to"nearest: Well Foundation Property Line <br /> SEEPAf3E PITS 11 Depth ! Size I Number T <br /> SUMPS4 Ll Distance to nearest: Well ` t Foundation `-" 4Propeny Line <br /> DISPOSAL PONDS-, D <br /> I hereby cenify that I have prepared this application and Lhat the work will be done•in­accordance 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 certifies the following; "I certify that in the performance of the work for which this permit is issued. I shall not t <br /> employ any person in such manner as to become subject to workman's compensation laws of Ca6lornia." Contractor's hiring or sub-contracting:signature r <br /> certifies!the fol{owing: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compen:a• <br /> tion laws of California." .' <br /> The applicant must call for all required inspeptions• Complete drawing on reverse side, / "f <br /> Sired ) Title: Date: <br /> i F DEPARTMENT USE ONLY f <br /> `.� <br /> i <br /> Application Accepted by Date Area <br /> l / <br /> Pit or io Inspection by� Date Final Inspection b T Date <br /> „l _Z7= ,. <br /> Additional Comments: <br /> Applice,nt - Return all copies to: SANJ06QUIN COUNTY PUBLIC HEALTH SERVICES <br /> i. ENVIRONMENTAL HEALTH DIVISION-PERMIT/SERVICES ; <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 f <br /> FEE AMOUNT D AMOUNT REMIDTEO CASH RECEIVED BY DATE PERMIT'NO.` <br /> INFO <br /> -.- 3 <br /> „�sr ,F ` i�. ,9 ��3 <br /> -Jo - 313 `� <br />