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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> XZAA PROLDATE ISSUED <br /> (Complete in Triplicate) <br />{ Application is hereby made fo 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 Health Services. <br /> Job Address / l Cit Lot Size/Acreage i <br /> Owner's Name telAddress hone Za <br /> r <br /> Canirac 4 Address lotl 16L C_CL License No.t1 3 Phone & <br /> TYPE OF ELL/PUMP: NEW WELL 29t WELL REPLACEMENT n DESTRUCTION 0 Out of Service well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR 111OTHER C Monitoring well C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK 3Dm SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing d( <br /> P Domestic/Private ikG(avel Pack 0 Tracy Type of Casing s Specification's <br /> M Public 0 Other 0 Delta Depth of Grout Seal Type of Grout !" <br /> G Irrigation /4&.Approx. 'Depth ❑ aste`m','1 Surface Seal Installed by �r J <br /> Repair Work Done L7 Type of Pum o2State Work Done <br /> p e_ <br /> Well Destruction D Well Diameter 140 Sealing Material i Depth <br /> d <br /> Depth n 49 Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION L} REPAIR/ADDITION Irl DESTRUCTION Ci {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence• Commercial r. Other �[ <br /> Number of living units: Number of bedrooms ! �+ <br /> Character of toil to a depth of 3 }est: Water table depth <br /> SEPTIC-TANK: O Type/Mfg Capacity No. Compartments' <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> I <br /> Distance to nearest: Weil Foundation Property`Line <br /> i <br /> LEACHING LINE Q No. & Length of lines <br /> - 9 _ _ Total length/size b <br /> FILTER BED 0 Distance to nearest; Well _ Foundation _ Property Line <br /> SEEPAGE PITS i I Depth I ,� • SireNumber <br /> SUMPS 0 Distance to nearest: .Well Foundation Property Lina <br /> DISPOSAL.PONDS p ,. <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 San Joa>auin bounty <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 fo workman's compensation Lbws 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 /> tion laws of California." <br /> The applicant must c4ij for all required ' Ctions. Complete drawing on reverse side, <br /> �v 5 <br /> Signed Title: 4 Date: <br /> k <br /> OR DEPARTMENT USE ONLY � Y� <br /> Application Accepted by µ Date <br /> x� Area <br /> Pit or Grout Inspection by Date Final Inspection_ by <br /> Additional Comments, <br /> Applicant - Return all copies to: 9AN,JOAQUIN.COUNTY PUBLIC HEALTH SERVICES d, <br /> ENVIRONMENTAL HEALTH -DIVISION PERMIT/SERVICES -- <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA' 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GK RECEIVED 8Y DATE PERMIT'NO. <br /> INFO CASH i <br /> . IH13-24 iREV.11K51 1 .� ( <br /> FH A-7436=a u <br />