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5i <br /> APPLICATION FOR PERMIT <br /> �: k <br /> SANIpAQUIN COUNTY PUBLIC REALTH S VICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCgTON, CA 95201 <br /> (2'09) 468-3447 <br /> k ap�.r`wRISTT F IR$S 1 YEAR rROY DATE. ISSUE <br /> (Complete in Triplicate) <br /> Application is hereby made"to Sao Joaquin County fora permit to construct and/or install the work herein described. This i <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. k <br /> fA L' 2T� City o Lot Size/Acreage - <br /> Job Address R <br /> r <br /> r Adds �v _-„ r-14PP_ 2 p Phone U " <br /> owner'ri Name Address <br /> GonGactor 1u' «e Address License No. 2 � _Phone ` <br /> TYPE OF WELL/PUMP; NEW WELL 1) WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Weli 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER g r,jlf oriApr(ing well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS ._ <br /> INTENDED USE TYPE OF WEL1. PROBLEM AREA CONSTRUCTION SPECIFICATIONS fr <br /> ntrill ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing <br /> estic/Private ❑ Gravel Pack n Tracy Type of Casing Specifications , ^ <br /> Z1 Pubfic 1:1 Other 0 Delta Depth of Grout Sea, SO Grout <br /> rn SurfU 1 <br /> cJ IrriUarion _. Approx. Depth fl Easteace Saul Installed by�_ r^`O al N'o�n - <br /> Repair Work Done U Type of Pump H.P.R State Work Done _ <br /> Well Destruction ��Well Diameter- Sesliog M+kterial i Depth �Sl� G ,. <br /> c .1..T 'gyp <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION Li REPAIR'/ADOITION 0 DESTRUCTION G (No septic system permitted if public sewer is <br /> `R available within 200 feet.l <br /> Installation will serve: Residence— Commercial Other 4 <br />► Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity-_;—. No. Compartrr ants <br /> PKG:`TREATMENT PLT,Irl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L-1 No. 8 Length of lines " Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well ' Foundation Property Line <br /> _ SEEPAGE PITS 1 1 Depth Sire Number f Ir <br /> SUMPS Ll Distance to nearest WON Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in a"ordance with San Joaquin county ordinances, stale Laws, and <br /> rules'and regulations of the San Joaquin County f. <br /> 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, 1 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 the following: "I rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. <br /> tion Is"of Calit <br /> The applic must c f r wired inspections. Complete drawing on reverse side. <br /> Signed Title: . Date- <br /> F0?,9 DEPARTMENT USE ONLY <br /> Application Accepted by Date ✓ Area - <br /> r r ro <br /> Pit ar Grout Inspection by Date Final Inspection by Date.. .��f� <br /> r <br /> Additional Comments: O _ <br /> x -4 <br /> Applicant - Return a].1 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> x IE ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O SOX 2009, STOCKTON, CA 95261 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYn DATE J PERMIT'NO. <br /> . EH 13.2{IREV;` s1 1 A0 ! <br /> EH 14-2111 <br />