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APPLICATION FOR PERMIT <br /> A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit'to construct and/or install the vork 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 rPublic Health Services. r_1 <br /> t �1` <br /> Job Addrsas + City Lot Sire/Acreage �j <br /> ��Owner's Name _ Address r"one7, ` ��� <br /> � Contractor <br /> Addres 3 n �_ — LicerLftyeNA699 Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ; WELL REPLACEMENT [-} DESTRUCTION ❑ Out of Service Well Cl <br /> t PUMP INSTALLATION ❑ ,SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> .DISTANCE TO NEAREST:-'S'EPTIC 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 /> ! Industrial ❑5ottom O Manteca Dia. of eN Excavation "—" Dia. of W <br /> f 0pen Bell Casing <br /> U Oomestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications- <br /> M Public f"I Other ❑ Delta Depth of Grout Seal Type of Grout f <br /> Cl lrrigation -2— Approx. Depth b Eastern Surface Seal installed by t <br /> 'Repair Work Done L7_Yype of Pump ; H.P! I State Work Done t E <br /> iWell Destruction O WeII Oiemeter { Sealing Material i Depfh +. i "�• ° ' <br /> Depth t Filler �Material�& Depth � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIRlADDITION !DESTRUCTION CI (No septic system permitted ifpublic sewer is` ^^ <br /> available within 200•lest.I <br /> Installation will serve: Residence 4 Commercial <br /> t � Other <br /> Fi <br /> I Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: ' 1v " �^— �' Water table depth <br /> SEPTIC TANK Type/Mfg f pa city ZLNo:Compartments <br /> `PKG, TREATMENT PLT. Cl `-�f„ Method of Disposal <br /> i Distance to nearest: Well lg:� .,T Foundation. r Property Line <br /> � <br /> LEACHING LINE . No. & Length of lines ; Taal length/size <br /> f/ 1 <br /> 7FILTEA BED [:l Distance to nearest: Well_62..;�,_.: Foundation Property•,Lins•r � � * <br /> t <br /> `SEEPAGE PITS Depth— Ct'• _Size Number <br /> : <br /> SUMPS LI Distance to nearest Well Foundation Property Lina r <br /> DISPOSAL PO�NDS 0 <br /> it hereby certify:that I have preparod0is application and that the work will be done in accordance with-San Joaquin county ordinances, state laws, and <br /> rules.and regulations of the Sari Joaquin County. 1 <br /> Home owner or licensed agent's signature certifies the foilowing: "I certify that inJKs,performance of the work for which this permit is issued, I-shall not <br /> employ any person in such manner as to become subjeci 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 iisued l shall,employ persons'subject to workman's compensa• i <br /> tlon laws of California." r ' { <br /> ,The applicant m et call for allrequired 'r ons Conn plate awing o averse side. a� <br /> Signed Titla: `Date: <br /> FOR DEPARTMENT USE ONLY fi <br /> t r, a . — Area <br /> Application Acceptod`6y Dat <br /> , <br /> 9C or.•Grout Inspection by t Fine Inspection by <br /> 4Dats <br /> - <br /> Addidoilel Comments:�/�9 ���� _� •-- l — <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �-• � �� (�(� <br /> , . :._ENV-IRONidFNTAL'liEAiTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 05201 <br /> b <br /> AMOUNT DUE" AMOUNT <br /> !UN�/T/fEMITED CK RECEIVED BYE DATE _ +PERMIT'NO. <br /> AASH'\;INFOCAS <br /> 13-24 IREV. <br /> t2 -TA_fi/ <br />