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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EMIRES 1 YEAR FROM DATZ ISSUED <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This <br /> application is made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City L�i4Q City Lot Site/Acreage <br /> 2 <br /> Owner's Name LAZ 6W eZ Address Ti 1��1 � WADPhone C/�"�-r r <br /> Contractor/ Z�AZ*el_ Addresvo 3 W'Alw)cll 4AJ Ste* License No.,V/Z?3 9 Phone V&�O^0 <br /> TYPE Of WELL/PUMP: NEW WEL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service dell ❑ <br /> PUMP INSTALLATION 7 SYSTEM PEPAIR ❑ OT ER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES N DISPOSAL FLO.N PROP. LINE ZO �31)C <br /> FOUNDATION 1 AGRICULTURE WELLS /E" OTHER WELL._ PITS/SUMPS�� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �� r <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation--I/ Dia. of Well Casing <br /> Domestic/Private C1 Gravel Pack 0 Tracy Type of Casing__ek-LSpecifications i <br /> Public 1-1 Other n Delta Depth of Grout Seal 3O Type of Grout <br /> I I Irrigation —Approx. Depthy�+ Eastern Surface Seal Installed by g"fr`+�lBiL! <br /> Repair Work Done U Type of Pump /_ H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth pa <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units'. Number of bedrooms <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. k Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line a <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 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 <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 /> canifin 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 applicant c f squired i pections. Complete drawing on re ersa side. <br /> Signed Title: 7/f+�t'� Tt-r' SAY >]ata: ✓?r�� <br /> FOR DEPARTMENT USE ONLY �j <br /> Application Accepted by Date cl Area r <br /> g� <br /> Pit or Grout impaction byi_ 0 Date Final Inspection by �' Date <br /> Additional Comments:SA4 ��^'� f/lrtt. Q► T i `� <br /> Applicant - Return all copies to: San Joaquin County Public Health Services r/ <br /> Environmental Health Permit/Services _l i <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE c <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> « Ell 132<[ACV,i Pt 5) Gtr ct (� 7 �� , -psvA <br /> Etl i�•2e f� 7 7 U <br />