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j1- 9.S F,— APPLICATION FOR .PERMIT <br /> 1,3 -!°!-0-14 V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> '0/ .- 1(3 S'A oz) - EN V I RONNIENTAL HEALTH DIVISION <br /> l3 - /��o 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> ;t <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES X YEAR FROM DATE I$SUFD <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 incompliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione of San <br /> Joaquin County Public Health Services. <br /> Job Address Z62 1. �` ._f a-,. � t r"�l /_4 ___ ___ City C Lot Slze/Acreage r / <br /> Owner's Name Je�r!'l- "t' ��_ f 4 i Address /�', 7 Yu I� YYA 7 171--a e t _ Phone <br /> �, . 1� edit� '• oirl f r /n 7 Phone <br /> Contractor 'tZ L- ti C' Address License No. ' <br /> TYPE OF WELL/PUMP: 'jI ;NEW WELL Ai WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER O Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK /L?T SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ��' <br /> INTENDED USE $TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial tQ Open Bottom ❑ Manteca pia. of Well Excavation s Dia. of Well Casing <br /> pomesticlPrivata° Gravel Packel <br /> Tracy Type of Casing__ , t Specifications !��^ .._,_� <br /> I'1 Public F-1 Other Cl Delta Depth of Grout Seal A Type of;Grout AggZAAlt1�tt'_� <br /> I i Irrigation i Approx. Depth I I Eastern Surface Saul Installed by <br /> Repair Work Done U Tro of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth Torrfl rc/E <br /> pepth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> II; .- available within 200 leel.I <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: 'Ip1 Number of bedrooms -t <br /> Character of soil to a depih of 3 feet: Water table depth i <br /> SEPTIC TANK 0Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl'I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl' No:8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to rarest: Well Foundation Property Line <br /> ! SEEPAGE PITS 1 1.1 Depth Size Number T <br /> SUMPS Lia Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0,l <br /> I hereby cenify 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 againt's isignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> i 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 compen:;`" <br /> tion laws of California." I� <br /> The applicant st call for ail requir inspections. Complete drawing reverse ' e. <br /> ti- <br /> Signed Title: Data: �� <br /> FOR DEP TMENT USE ONLY <br /> Application Accepted by I� Date -,7)2//fArea <br /> � .� . <br /> Pit or Grout Inspection by ,I�. Data Final inspection by <br /> i <br /> Additional Comments: L` � r <br /> Applicant - Returnl�ail copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services ' <br /> 445 N San Joaquin, P O Box 2005, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMWNO'. <br /> INFO CASH <br /> . <br /> EH 374IREv.rixsr W � t j t3 <br /> EH 74.16 .l I ��_ <br />