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APPLICATION FOR PERMIT <br /> SAN JUIN COUNTY PUBLIC HEALTH ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUID <br /> (Complete in Triplicate) <br /> Application is hereby made tq San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1062 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. // Lei), g/ \1 �7� <br /> ''// S ���-�Y+-�E W17� F-/�/ City ir-t✓� Lot Size/Acreage <br /> Job Address �b <br /> /, l � Wiz. ✓�v' 17-40 IP D. eA Phone <br /> Owner's Name ot-E M (MALR �&��- '� Address CEJ p^-e <br /> w(..��AtADIT p2tLt.IhlC1/Address K�"3 � MAQ��y License No. 5 j(,31A Pnon -d7- <br /> Contractor service Well- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of <br /> Well <br /> n❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ SO/G LO/Z/;( <br /> ,,/^ DISPOSAL FLD.�� PROP. LINE 1,1 <br /> DISTANCE TO NEAREST: SEPTIC TANK '�'7`�°��— SEWER LINES <br /> FOUNDATION 3fO r AGRICULTURE WELL .�- OTHER WELL ,v/A PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Dia. of Well Excavation <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> T of Casin _ WltA Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack [1 Tracy❑ Delta Depth of Gross Seal �1 Type of Grout N12 cEbl. <br /> I'1 Public ❑ Other <br /> if Irrigation —Approx. Depth )<Eastern Surface Seat Installed by <br /> H.P. State Work Done _ <br /> Repair Work Done U Type of Pump Sealing Material L Depth ^�^'�r� /'OAlT't1'� <br /> Well Destruction ❑ Well Diameter filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I aNailabPe 'w Thin leasystem it public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: _ Number of bedrooms <br /> Water table depth <br /> Character of ii to a depth of 3 feet: <br /> SEPTIC TANK C3 Type/Mfg Capacity No. Compartments <br /> Method of DisposalPKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE ❑ No. A Length or linea Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS - LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 agents 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 compenss <br /> tion Owe of California." <br /> The applicant m t call 'r aW ctions. Complete drawing on rover" side. - <br /> Signed <br /> Title: �P/J/C/'T C �'�L- Date: <br /> l!JJIIL� FOR DEPARTMENT USE ONLY <br /> /�17�..vt S G 9 3 Area <br /> Application Accepted DV Date } <br /> Pit or Grout Impaction by f`�' � Date Final Inspection by e`=''�4 Data � y� <br /> Additional Comments: -�A? >T <br /> Applicant - Re all copies to: ❑ Joaquin County Public Hea Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE MOUN7 DDE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO AA CASH <br /> . EH I11e IafV.irms� �f C', <br />