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a �, '�4 I ' is•.. j E}}Y� 7z ri;.i;i�k+rl W ,� r At0 1 r-R e+ • t3tb*r,i.' t 011 S �F� -�HC�„� s' f �. f �,��'�Yi ♦ �J.p� �iT 1 7d ff�yW t;. • f �'.,-ii- �`:✓�.Lw)t�.n5n t•.`r1,� .._ _ •t _ .. ..rW%S- y�_ i �.,.+. APPLICATION'FOR PERMIT ; P . 7 aSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `; 1601 EH ENVIRONMENTAL AZfiLTORN AVE PHONfi II(209)468-3420 .` P O BOR 2009, STOCKTON, CA 95201 j PERtalrr EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) Y.. Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein descrihed. This <<� aTlpllcation is made in coopllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulat.lone of San • Joaquin County PUbli Heal rvlces. j D,ty�`/ _ Lot Site/Acreage '• Job Address Owner's Name AddJess * nPhone f� ' No. Phone _ C to ens " TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME T Cl DESTRUCTION G Out of Service Woll E Monitoring Well PUMP INSTALLATION,G SYSTEM REPAIR ❑ OTHER O n t DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD..__ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i �'• INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i Cl nduatral G Open Bottom ❑ Manteca Dia.of Well Excavation Dla.of Well Casing ; stic/Private D Gravel Pack ❑Tracy Tvpe cf Casing__ Specifications r I 1 Pubic fl Other fl Delta Depth of Grout Seal Type of Grout KIrrigatron __Appro■. Dep h a tern / unlace Saul Installed by St Repair Work Done U Type of Pump H.P. _ State Work D i t Well Destruction O Well Diameter Sealing Material iDepth i k Depth 0 filler Material L Depth jL✓ r• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR r ADDI TICK I I OFSTRUCTION I I (No septic system permitted it public"War is available within 200 feet.l - Installation will serve: Residence— Commercial_ Other 1 Number or living units:. Number of bedrooms r 1 Character of seal to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Cepacity No.Compartments v PKG.TREATMENT PLT.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No.b Length of lines Total length/size FILTER BFD ❑ Distance to nearest: Wel! Foundation Property line u SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ord4nancef,itto a laws,and .t rules and regulations of the San Joaquin County :f Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall not employ any portion in such manner as to become subpct to workman's compensation laws of California."Contractors hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I stall employ persons subjoct to workman's compensa• tion laws of California." c` r The applies at cal forAll faiclu,red.in"c t ions. Complete drawing on rove to side. Signe /1A/ I L/1 Title: Date: ` FOR DEPARTMENT USE ONLY Applict4ion Accepted by " Date Area ,y. Pit or Grout Inspection by _. Date Finallnspection by Data Z/ Z ,�. Additional Comments: R Applicant — Return all cople: to: San Joaquin County Public Health ,y Services, Environmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 { _ IF E AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0. .. EMt)NIeEV.rinei � EN taia t t l i . y