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i4 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 /> lIRES 1 Y <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cOVV1iance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> ` Joaquin County Public Health Services.� l <br /> Job Address $ Ga.e ! V�• City-• Y �YzL e- Lot Size/Acreage <br /> Owner'sName U Y1 OC'n' ef)r,b. Address DOD eno (&07 9On g a7 — 0343 <br /> Phon+� <br /> Contractor r "' ��rr ] rry�t� _ <br /> 4 sL� .�`n17#'e r :_Address Q <br /> TYPE OF WELL/PUMP: <br /> License No. Phon <br /> NEV)NE ELL,'K WELL REPLACEMENT ❑ DESTRUCTION—Dout of Service dell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom El Manteca <br /> _ Dia. of Well Excavation rr <br /> U DOnleati0Private 0 Grave? Pack' Dia. of Well Casing <br /> lS�Tracy Type of Casing��.40 P vcr, <br /> ❑ Del <br /> ❑ Public Cl Other t Specifications o <br /> Delta depth of Grout Seal 10 /QTYpe of Grout <br /> lnipation ��Approx, Depth ❑ Eastern Surface Seal Installed by CcL[. �GYM ,• J r <br /> Repair Work Done 0 Type of Pump H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth State Work pons <br /> Depth t Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION Ll DESTRUCTION CI (No septic $ srem <br /> # P Y permitted if public sewer is <br /> Installation will serve, Residence_ ICommercial_ Other available within 200 feet,) <br /> Number of living units: Number of bedrooms <br /> Character of*oil to a depth of 3 feet: , <br /> SEPTIC TANK, 1 Water table depth <br /> ❑ Type/Mfg <br /> EKG. TREATMENT PLT. ❑ Capacity No. Compartments i <br /> ) <br /> f Method of Disposal <br /> Distance to nearest: Well Foundation <br /> _ _ Property Line <br /> LEACHING LINE Cl No. b Length of lines G <br /> FILTER BED Total length/sire <br /> (I Distance to nearest: Well s Foundation f <br /> � Property Lino , <br /> SEEPAGE PITS 11 Depth <br /> Sire Number ` <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS ❑. Foundation _ Property Lina <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 I <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 F <br /> employ any person in such manner as to becoms 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 em to <br /> tion laws of California." A D y persons subject to workmen's eompen:a• <br /> The ippticantIl f 11 requir ape rOna. Complete drawing On rev side. <br /> Signed ` ` <br /> Title: <br /> Data: 7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Data 77 Arae f /Y✓ C f <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Data <br /> Additional Comments: r SAN JOAQUIN COUNTY-PUBLIC HEALTH SERVI <br /> Applicant - Return all copies to: gAj JOAQUIN COUNTY PUBLIC HEALTH 9 'CES <br /> 445INONMENTAL SAN JOAQUIN, -0 HEALTH <br /> DIVISION BOX2009ER9 Q1 IAL PERMIT <br /> FEE <br /> INFO AMOUNT DuE AMpUN7 REMiTTEO CK <br /> CASH AECEIVED BY DATE PERMIT'NO, <br />. EH 1344IREV,tin6i !A/1 A y QD <br /> EH:�•Zis 1 1.1�� C.� �{ 11 <br /> / ` �•:.r <br />