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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 408-3447 <br /> PEMIT E%PLRLS 1 YEAR fAOM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is here made to San Joaquin Count for a <br />� ]7P by q Y permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin Country Public Health Services. .�} A <br /> Job Address - I �,Z� � � A�,fE City l�_'�`Y Lot Site/Acreage <br /> r Owner'i,Name ! lCJf/ �7 Address '. Phon <br /> Contra cip -�IY�Address- + / Licenpif N �� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1=1 DESTRUCTION ❑ Out or Service Well 0 <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> E DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP LINE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS # <br /> Cl Industrial ❑ Open Bouom ❑ Manteca f- Dia. of Well Excavation DIa, of Well Casing <br /> U Domestic/Private 0 Gravel Pack E3 Tracy Type of Casing Specifications <br /> 1M Public CI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> f <br /> CJ Irrigation .,�.Approa, Depth fl Eastern ., Surface Seal Installed by <br /> Repair Werk Done ❑ Type of.Pump f _ rH.P.„ 7 Stete.Work Done 1 <br /> Well Destruction © Well Diameter 1 Sealing Material i Depth U7 <br /> i Depth Filler Materialt&,Depth (""1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIRIADDITION 'DESTRUCTION G (No septic system permitted i( ptrblic sower is <br /> - .w t- available within 200 feet.) <br /> Installation will serve: ' Residence Commercial_ ther <br /> ` Number of living units: Number of bedrooms r <br /> Character of soil'to a depth of 3Ffeet: _ /V Water table depth <br /> SEPTIC TANK X, Type+/Mfg ` Capacity No. Compartments <br /> PKG. TREATMENT PLT10 Method of Disposal <br /> Distance to nearest: Well �. Foundation ��_ Property Liner__- <br /> LEACHING LINE ., i 19C,No. b Length of lines ZC3 �3 410°"- otal length/size <br /> FILTER BED n Dist{ce,to nearest: Wall-_&IC7 Foundation r Property Line 30�� 'oF G <br /> SEEPAGE PITS 11 1 'Dapttt �_ r ° Siie g X/� Number <br /> �.A <br /> SUMPS Distance to neatest: WeilFoundation <br /> E SO.. Propafty Line- <br /> DISPOSAL PONDS fa ) <br /> I hereby certify that I have prepared this application_an_d that the work will be a donein_accordance with Sa.n Joe ui ;county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensad agent's signature certifies the followings"I certify that in.ihe performance of the work for which this perrhit is issued, f 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 /> tlon laws of California." * i I I <br /> The applicant must for req red inspe,�tions. mplete drawing.. erse�.slde. <br /> I <br /> Signed i Title:. �' - -I. <br /> Dete: <br /> DR DEPARTMENT USE ONLY E <br /> Z <br /> Application Accepted by r Dateeli A ea <br /> Pit or Grout Inspection by r * Date Final Inspection byDate <br /> Additional Comments: ' /a / <br /> t <br /> Applicant - Return all copieetito:.-SAN-JOAQUIN COUNTY-PUBLIC EAI:TH SERVICE -. <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES t .. <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEE INFO AMOUNT}DUE AMOUrTIiT REMlTTE'D [ASH a RECEIVED I3Y DATE PERMIT NO. <br /> . EN13.147REV.ii"SrSR -A11y't�'� :!t> 1ygOQ 18003 W 1--T 1,7s h � <br /> EN 74.16 <br />