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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEICES <br /> ENVIROMgENTAL HEALTH D I <br /> �\ 445 N SAN JOAQUIN, PHONE (2 9 8-3420 J <br /> P O BOX 2009, STOCKTON, <br /> PERMIT WIRES 1 YEAR FROM <br /> (Complete in Triplic e # Y <br /> Application is hereby made.to San Joaquin County for a permit to construct a d/� efJx1179 — s <br /> application is made in COMPliance V1th San Joaquin County Ordinance No. 549 the Rules and Regulations of San <br /> Joaquin County Public Health <br /> Services. <br /> JobAddress `�:k4"\TN ` City NALSv <br /> Lot Size/Acreage <br /> Owner's Name r'F� q Address 1Q3� ly1c`'A 41N. Phone <br /> Con tfac I OA�mmC A, Vl'� Address W- ,v% p 11► License NoA1W L&, -Phone ­'�A' O� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cr- - -DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR I OTHER ❑ Monitoring Kell C]L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. � <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavption' r Dia. of Weil Casing <br /> _ 1 <br /> XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public fa Other F1 Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation _Approx. Depth l I Easternurface Seat Installed by <br /> i <br /> Repair Work Done ' Type of Pump TV H.P. 4 State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Naterial & Depth <br /> Depth Tiller Nsterial i Depth Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIRIADDITION I I DESTRUCTION I I (No 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 soli to a depth of 3 feet: Water table depth <br /> -SEPTIC TANK. ❑ Type/Mfgcity.ly No. Compartments - <br /> PKG. TREATMENT PLT. ❑ <br /> C 2 Method of Disposal <br /> Distance to nearest: Well__ R u 4tionBOG <br /> .-�._,.� Property Lina <br /> quaulp4 c r.,_ <br /> LEACHING LINE Ll No. b Length of lines _ -. VIRQM f�j�� h�Etd�I�ngth/size <br /> FILTER BED 13 Distance to nearest: Well Foundation- LT LiV1Sf( pony Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ul Distance to nearest: Well Foundation Property Lina <br /> --DISPOSAL <br /> PONDS 17,0'= <br /> t 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 1 <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 /> cartifia tlta 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 call for all required inspections. Complete drswin on reverse side. <br /> Signed X. „�. Title: oo�Ltl4„1y` Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 9 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> �j 445 N Sae Joaquin,, P O Hoa 2009, Stke, CA 95201 <br /> Y <br /> FEE AMOUNT DUE AMOUNT REMITTED ` RECEIVED BY DATE PERMIT'NO. <br /> IN LA I <br /> • EN 13-241REV.11e5) L+ 4'c <br /> EN 1420 <br /> j <br /> 1 <br />