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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br />• 445 N SAN JOAQUIN, PHONE (209)4683420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM 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 made in coc;pliance with San Joaquin County Ordinance No 51+9 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services <br /> .lob Addre-./ Xz �r �� �Q'� City Lot Size/Acreage <br /> Owners Name -/Zt!"i/Qe5iIf, S Address / �s /SIIAJ % �C/� e'v - 00 <br /> Contractor �• Address + Z? �� v :rq icense No S-cr/F_3`[__Phof�e 7 L�t'-y-%d 0 <br /> TYPE OF WELL/PUMP NEW WELL ^,V ' WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ;W14cuZitoring 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 /> * Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing <br /> n Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> I I Public n Other n Delta Depth of Grout Seal Type of Grout�f,��«cJ=, <br /> I I Irrigat+on Approx Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done D Type of Pump H P State Work Dane _ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Tiller Material i Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 leaf I <br /> Installation will serve Residence_ Commercial— Other <br /> Number W Irving 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 ❑ Method of Disposal <br /> Distance to nearest Well Foundation Property Line <br /> LEACHING LINE ❑ No b Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sue 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 agent a signature certifies the following I certify that in the performance of tate work for which this permit is issued t shall not <br /> employ any person in such manner as to become subject to workman s compensation taws 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 a compenca <br /> hon laws of California " <br /> The applicant must call for all required Inc tions Complete drawing on reverse side <br /> Signed - tie ���.✓�/� Date <br /> Z `t G U 5 <br /> }}}{(/n FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �" Area l fl <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 /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AI"i/y0U�N�/77/DU/E AMOU/N-7TH RE,MIIT/TIED CASHE RECIE(IVED BY � D/ATE(, PERM17 NO <br /> t}24 iFEV 7/%5i V I V( 1 0CJ {lLS ! (WA -! 1{ T 7 <br />