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APPL,I CATI ON FOR P&M I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> SNVIRONNENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PEONS (209)468-3420 <br /> P O BOB 2009, STOCKTON, CA 95201 <br /> RERNIT EXPIRES I YEAR FROM DAT 16§TIS <br /> (Complete in Triplicate), <br /> Application is hereby stada to sea Joaquin+County for a permit to construct and/or install the work herein described. This <br /> application is made in ectiliance.trith Ban Joaquin County Ordinance No. 549 arid. 3,862 and the Rules and Regulations of San <br /> Joaquin County,Public odalth'Berricas. <br /> Job Address �,3;1?�r� �DS f�f.+• City Int Size/Acreage /50 <br /> i <br /> .��,� !fir �--y���,�� �,�.�.. �>��.�- <br /> Owner's Nsms Address � <br /> � Phone <br /> Contractor M5N AddressS License No. l_3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL F WELL REPLACE ENT 0 DESTRUCTION 0 Out of Service ;fell-0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring ;tell O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.IM PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ��,,�� Dia.of Well Casing 162 <br /> n Owtestic/Private X Gravel Pack Id Tracy Type of Casing_ `-Ida�? Specifications I <br /> !'1 Public CZ Other fl Delta Depth of Grout Seal w /11T7 _ Trout La2+XeA7�" <br /> Irrigation _Approx. Depth 1 I Eastern Surface Saul Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Dons r <br /> Well Destruction O Well Diameter Sealing Naterial A Depth <br /> r Depth Filler llsterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 fast.) <br /> Installation will serve: Rpfdenoe— Commercial_ Other Q <br /> Number of living units: Number of bedrooms PAYMENT Ln <br /> Character of soil to a depth of 3 feet: Water It / <br /> SEPTIC TANK O Tyys/Mfg Capacity flAethCott piptsp�s� •�. <br /> f1 PKG.TREATMENT PLT.p b\ <br /> Y2 Distance to nearest: Well Foundation Property + } AQ�>iIP�GOUNTY <br /> PI IRf 4 L ICA i Til MWI•CES [ <br /> LEACHING LINE n No, 6 Length of lines Total langtl�l�M - 1h <br /> FILTER BED ❑ Distance to nearest: Wed Foundation . Property Lire <br /> SEEPAGE PITS I i Depth sire Number <br /> SUMPS LI Disunos to nearest; Wall Foundation Property Line <br /> DISPOSAL PONDS 0. , <br /> I 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 /> 1 Home owner or konsod agent's signature osrtirm 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 ire fotbwinp:"I eerritY that in the performance of the work for which this parmsteel <br /> it is issued,I employ persons subject to workman's compensa. <br /> tion laws of California." <br /> The applicant It tap for an requi nspections.Co piste drawing on verse side <br /> Signed XTills: Date: :�! _ <br /> . DEPAR ENT USE ONLY <br /> Application Accepted by Data Z Q-3 Arse -7-/6 <br /> j Pit or Grout inspection by Date Final ImpactionhY Date* R3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health services <br /> Environmental Health Permit/Services <br /> 445 S Ban Joaquin, O Box 2009, Stkn, OA 05201 <br /> FEE I ZI *ehF,vz) <br /> AM014 QUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT N0. <br /> • fel 13.24 tRiv.4/A51 Lo <br /> , <br /> IN 1440 v 7 \i <br />