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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> X 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FRgM DATE ISSUED <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 Stade in couipliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> {� r <br /> Job Address _ � � +� l�l� of lmv S ed, City C Lot Size/Acreage �j <br /> /�/fn�] . r -J /� U�C9 ^/U <br /> Owner's Name&.,. �- Let,y it 911A&S Address c`?do®d �►^94, }�JC/�2-- - - _- ---__ Phone <br /> Contractor tI k �JCAddress 111 License ro� Phon <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK LfW` 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 /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wait Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack7 0 Tracy Type of Casing_ &;::� ___�_____� Specifications <br /> 1"1 Public F1 Other F1 Delta Depth of Grout Seal fd Typ9 of Grout <br /> I I Irrigation x. pth l I Eastern Surface Saai Installed by r r. e <br /> Repair Work Done U Type of Pump H.P. State Work Done N <br /> Wall Destruction ❑ Well Diameter Sealing Material i Depth <br /> N Depth Filler Material L 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 twit to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> T,PKG. TREATMENT PLT.❑ Method of Disposal d <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. 6 Length of lines Tota! length/size <br /> FILTER BED ❑ Distance to nearest. WO Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS LI Distance to nearest: Well ; Foundation Property Line <br /> DISPOSAL PONDS 0 <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 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 /> cartifisa the foMewing: "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 fNat call for ail required inspections. Complete drawing on reverse side. <br /> Signed Title: u L GiGh _ .—._ Date: V---3p,2 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1 Date —-i��� 12- Area ©� b <br /> Pit orrou I spoction b Dated Final In coon by Date <br /> Additional Comments: 4� F m <br /> Applicant - Return all copies to: San Joaquin County Public Health Service- <br /> Environmental <br /> ervice Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Hoa 2009, Stkn, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED `CASH RECEIVED BY DATE PERMIT'NO. <br /> . EN14-2,111Ev.t/N5) W• 2 1 >0 � L � � 3Ll <br /> E"i •2aIto [�7CO q <br />