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APPLICATION FOR PERMdIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Rk cp , R> <br /> P O BOX 2009, STOCKTON, CA 95201 MAY. <br /> (209) 468-3447 . ENNONNJF"pq g f , ' <br /> R PERfo /S.RV Cry� 7� <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 coupL liance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health ServlVs. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name _GZ?J Q-56,4 ML L, 4_ Address 40 L_' Phone <br /> Conttacto ac Address — lG ���30X' y 3��Z _22r� <br /> ______ Icense-No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL YO ! WELL REPLACEMENT D DESTRUCTION,❑"Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ xOHER ❑ Monitoring Well G� <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 /> C7l Ind u rial O Open Bottom IDManteca Die. of Well Excavation Dia. of Well Casing <br /> omestic/Private Cf Gravel Pack n Tracy Type of Casing Specifications <br /> M Public 1:1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CI Irrigation Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. 7, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION CI (No septic system permitted it public sewer is f� <br /> Installation will serve: Residence— Commercial Other ` i <br /> available within 200 feet.) v <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. ❑ �, 3 <br /> Method of Disposal _ <br /> Distance to nearest: Well Foundation ' Property Line <br /> t h <br /> y r <br /> LEACHING'LINE Ll No. & Length of lines f Tota! length/size <br /> FILTER BED ❑ Distance to nearest:.- Well""`""" = Foundaiion"` - --Property Line <br /> SEEPAGE PITS 11 Depth Site <br /> Number 1 <br /> SUMPS Li Distance to nearest: Well Foundation Property Line ` <br /> DISPOSAL PONDS O <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 person in such manner as to become 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 employ persons subject to workman's compensa- <br /> tion laws of California." 1[ <br /> The applicant rnust_WAr all requirgd inspections. Complete drawing on reverse side' <br /> 4 <br /> Signed Title: AL9:1C= Date: 91 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Dace Ares 12/4 <br /> Pit or Grout Inspection by Date Final Inspection by Date S <br /> Additional Comments: I <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> INFE LA/MOOUU'NT DUE AMOUNT REMITTED —/CAS/H, RECEIVED BY �eDATE PERMIT'N0. <br /> EH EH <br /> ",4•2e <br />