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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)468-3420 <br /> P O 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 iaatall the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �7/� <br /> Job Address �j PJ City ^1' Lot Size/Acreage <br /> Owner's Name �f C b r� Address ti'• Phone <br /> Contractor L"P Address - 0`Mx <br /> License No. Phone IC <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT C-1 DESTRUCTION 0I of Service Well ❑ <br /> PUMP INSTALLATION.❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PI S/SUMPS <br /> INTENDED USE Y-TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> ❑ Industrial x ❑ Open Bottom © Manteca pia. of Well ExcavationXI <br /> Dia. oY"A <br /> EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public (-3 Other n Delta Depth of Grout Seal Type of Grout v <br /> I I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Tiller Material 4 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR/ADDITION �OESTRUCTION I I lNo septic system permitted it public sewer is <br /> y AR available feet.) <br /> Installation will serve: Residence_ ComaOther <br /> Number of living unite: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> t SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> _ w Distance to nearest: _ Well Foundation AO Property Line <br /> LEACHING L E' Cl No. & Length of linea __ l 40 X 3'o Total length/size <br /> r� BED Distance to nearest: Well E-2" Foundation �o° Property Line <br /> i <br /> SEEPAGE PITS 11 Depth " Size Number <br /> SUMPS LI Distance to nearest Well foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I hews 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's signature oertifiets the following: ­I certify that in the performance of the work for which this permit is issued, f shell not <br /> employ any person in such manes as to baeorrte 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 <br /> ft .laws of Csilfornis." permha <br /> it is issued,I shah employ persons subject to workman's eompansa <br /> The applicantall for all iced inspictions. Complete drawing on revs rsq side. <br /> Signed rL <br /> w Title: -�• Date: �L^ <br /> EMT USE ONLY y <br /> Application Accepted by —a, rr <br /> Date <br /> Pit or Grout Inspection by Date Final Inspection by Deli `- f <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 AMOUNT DUE AMOUNT REMITTED I CK CASH RECEIVED BY GATE PERMIT NO.EK 13-24 a <br /> EH 11•20IREY.f/est oQ ff!K <br /> a <br /> V V _ 462-3-2- � I <br />