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APPLI=CATION FOR PERM I T <br /> - SAN JOAQUIN COUNTYq.PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH ~� r-fi <br /> 6 445 N SAN JOAQUi Ilii, PHONE 2 �43_{,/.--— <br /> I P O BOX 2009, STOCKTON {{ CA 95201 <br /> PERMIT E%PIRES 1 YEAR FROM A1LPFAS_SUE_D _ <br /> + (Complete in Tripli`cF <br /> 1 � <br /> Application is hereby made,to San Joaquin County for a permit to constructs an tall tlo herein deeerib his <br /> ' application in made in compliance with San Joaquin County Ordinance No. .49 O e n <br /> Joaquin County Public Health Services, L Pu <br /> Job Address ri -` ie <br /> Z`A.1 City Lot Size/Acreage <br /> Owners Name T j'✓ ©0f/ - Address Phone <br /> G✓ Address �� License Nar �Tt-rPIton,_4,7_°'-� <br /> ' vontractor <br /> TYPE OF WELLlPUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well Gl <br /> PUMP INSTALLATION O SYSTEM REPAIR 52r OTHER ❑ Monitoring well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> tFOUNDATION „ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> ' wpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> it Public F1 Other rl Delta Depth of Grout Seat Type of Grout <br /> I I Irrigation Approx. Dep I Eastern Surface Seal Instalted.by.. <br /> Repair Work Done )' Type of Pump H.P. --.--�{.�— State Work Done <br /> ' Well Destruction 0 Well Diameter Sealit*'"flaterial 4 Depth <br /> Depth ftl-ler'Miterial A Depth c '11 r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR!AD®ITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 2W feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> ' Character of*off to s depth of 3 Pests _ Water table depth a <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT.0 a Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines - -Total length/size <br /> FILTER BED ❑ Distance to nearest: Well,: `* m, Foundation LT Property Line <br /> ' SEEPAGE PITS I I Depth Size Number <br /> SUMPS U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Daws, an <br /> rules and regulations of the San Joaquin County <br /> Home owner or fiansed 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 /> arnploy 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 compansa- <br /> t lion taws of Cali <br /> The appy t mus If for all requir inspections. Complete drawing on reverse ' <br /> Signed Title:_T � Date.- <br /> FOR <br /> ate:FOR DEPARTMENT USE ONLY <br /> X f <br /> Application Accepted'by V`-'a---r' Data Area <br /> Pit or Grout inepecWn by Date Final Inspection b_wdapldl ata <br /> ' Addhionsl Cornmsnta:_ <br /> Applicant - Return all copies to:`- San Joaquin County Publie 'Health Services <br /> vEnvironmental Health Permit/Services <br /> 445 1 N San Joaquin, P O Box'2009® 9 tkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE' PERMIT NO. <br /> INFO �`[ / <br /> �2� <br /> 5{i t4•25 <br />