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to APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 FILE -COPY <br /> S YAR <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 is e6411ance with San Joaquin County Ordinance No. 549 and 1862 and the <br /> Joaquin County Public Health Services. Rules and Regulations of Sen <br /> Job Address (.Q �J W 1,/ /L e 1( � , <br /> CityG t�' Lot Size/Acreage viuy QG e <br /> Owner's Name +'r Address _.U`(Ao 3 W T rn{y-!i' 3 - <br /> Phone <br /> &Contractor Address License No. <br /> TYPE OF WELL/PUMP; NEW WELL ❑ Phone <br /> LL REPLACEME ❑ DESTRUCTION ❑ Out of Service Wel ❑ <br /> PUMP INSTALLATION ❑ YSTEM REP IR G OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE LL OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST CTION SPECIFICATIONS <br /> 0 Industrial C1 Opener Bottom 0 Manteca Dia. Wa Excavation Die, of Well Casing <br /> Ci Domestic/Private 0 Gravel Pack 0 Tracy Ty Of Casi <br /> ('I Public 1� Other n pelta Specifications <br /> 11 Irrigation A pth of Grout sal Type of Grout <br /> Approx. Depth I I Eastern Surface Seal Insto ed by <br /> Repair Work Done C7 Type of Pump H.P. State Work pone_ <br /> Well Destruction ❑ Wall Diameter tae ins Material & Depth <br /> Depth liar Materia; &-Depth 4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ i REPAIR/ADDITION-1]. DE57RUC ON ;N \k <br />! ,. septic system permitted it public sewer is <br /> 1 Installation will serve; Residence Commerciale Other ailable within 200 feet.} <br /> Number of living units: Number of bedrooms <br /> Character of&Oil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth i <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. C1Capacity NO. Compartments <br /> Method of Disposal <br /> Distance tonearest: Well Foundation n __ Property line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED C] Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth _ �. ��Size <br /> SUMPS Number _... _ <br /> U Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS p <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,fno <br /> rules end regulations of the San Joaquin County <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, I shallemploy any person in such manner as to become subject to workman's compensation laws of California,"Contractor's hiring or subcontracting signa <br /> certifies the following:-I certify that in the performance of the work for which this permit is issued,I shell employ persons subject to workman's eompensa• <br /> tion taws Nifornia." , <br /> The eppl4anst II Bill red inspections. Complete drawing an reverse side, <br /> g q t <br /> Si ned% Title: Date: Z `� <br /> OR DEPARTMENT usE ONLY <br /> Applicatl n Accepted by Data <br /> Area <br /> Pit or Grout Inspection by Date <br /> Additional Comments: 1 w d\� L)Z\777 77M <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Haceltorn Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUfVT OU$ AMOUNT REMITTED C <br /> INFO �^ CASH AECEIVEO BY DATE PERM17ry'NO. <br /> • EH t3.26IREV.tin ar �,],'(J 0 B 0 /O �/ ! <br /> 7 <br />