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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, STOCKTON, CA 95201 <br /> PER6dIT E%PIRES 1 YE FR M D ISSUED <br /> (Complete in Triplicate) y <br /> Application is'h by made.to San'Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is mnde in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> j[Job Address /7/k ? n City /_t ___Rot Size/Acreage 115;f <br /> Owner's Name /t"t" ��gddrass I�3 N' VJ- � _0 <br /> Phone <br /> �_Contraclor RW Address 7ZI Al- M-J+Vf"~ License No. Phone� / — <br /> �" <br /> TYPE Of WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION•-❑ Out of Service Well 0 <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well n <br /> TDISTANCE 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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia:of Well Casing <br /> }n Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ 5 <br /> 1'1 Public "*� 1-1 Other f'1 Delta Depth of Grout Seat Type of Grow _ <br /> Type of Grout <br /> I I Irrigation —Approx. Depth l 1 Eastern Surface Seal Installed by f I <br /> �`Re�ii Work Done Q Type of Pump H.P. Stats Work Done <br /> Well Destruction ❑ Well Diameter' Sealing Material i.Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 tNo septic system permitted if public sewer is <br /> ..:available within 200 lost.M <br /> Installation will sem:. Residenca rCommercial _ ther ' <br /> erunits" _, -- <br /> Numbof IMna _/_ Number of bedrooms " _ 0. <br /> Character of&oil to a depth of 3 feet: & Water table depth," A <br /> SEPTIC_TANK. Type/Mf, C IPacityA"&*L No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Di$posal G 1 <br /> Distance to nearest: Well., Foundation t© Property Line.130' U Zy f P► <br /> LEACHING LINE "No. & Length of lines Y X <br /> Total length/size S zM ^ <br /> FILTER BED ❑ Distance to nearest: well Foundation 'r Property Line <br /> SEEPAGE PITS k Depth y, Size Zr ' <br /> Number <br /> SUMPS LI Distance to nearest: Well ; k Foundation Property Lina <br /> DISPOSAL PONDS ❑ ' <br /> I hereby certify that I 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, I shall not <br /> employ any pmson in such manner as to become subject to workman's compensation bw;yof California."Contractoi a hiring or sub contracting signature I <br /> certifies the following:-"f certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compense- , <br /> tion laws of California." <br /> 1 Thea must c I for all c uired inspections. Complete drawing on rave"rse+side. <br /> ]� <br /> Signed <br /> Title: <br /> Date: <br />} OR DEPARTMENT USE ONLY 11 <br /> Application Accepted by D ! =Lir Z� <br /> Oats_ —�7:.. [, ..,_ Area <br /> Pit or trout Inspection by Date Final Inspection by LbitipiIiiiat 1 1Date <br /> Additional Comments: — tbw <br /> Applicant - Return all copies to:-,Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CX RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> • EH M24IREV.I/AS) � � r?' �j+'� <br /> EH t4.76 000""" _ -Gtr 0J (C ;� 3 �r ,/ <br />