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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, STOC%TON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR ROM DATE ISSUED <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 in made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. �/ G� <br /> Job Address —_od_�92� 1`a`�tic7�� �Z City ���/ Lot Sixe/Acreage <br /> Owner's Name _ -�C'���� '� Address SS ° J r" "�- Phone <br /> Contractor [ 9 rZ Address S J '/ License N ��/ Phone 26a <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Yell ❑ <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 PITS/SUMPS <br /> — INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing <br /> EI Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I"I Public C7 Other it Delta Depth of Grout Seal Type of Grout <br /> l 1 Irigjatinn —Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth (� , <br /> Depth Tiller Material i Depth �J�xfJ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 -REPAIR/ADDITION^DESTRUCTION i 1 lNo septic system permitted if public sewer is <br /> available within 200 loot.I <br /> Installation will serve: Residence— Commercial OtherRAl U U t <br /> Number of living units: Number of bedrooms <br /> Character of loll to a depth of 3 feet: Water table depth l�� <br /> SEPTIC TANK. FE�­ Type/Mfg Oi7?tt_t- - 03 )r� 'L Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ r Method of Disposal <br /> Distance to nearest: Well Foundat n 10 Property Line <br /> LEACHING LINE U-__"No. 3 Length of linesTotal 4angth/size <br /> FILTER BED B Distance to nearest: Well ,0 • Foundation Property Line <br /> SEEPAGE PITS 1•+—Depth a2,1 i Sire 3611, Number <br /> SUMPS LI Distance to naeresC Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I hay*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 tete Sen 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 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 unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California," <br /> The applies call or all r uir inspection*. Complete drawing on reverse side. <br /> ` <br /> Signed X Title: 4etbC*t pate: <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Qate Fin I Inspection y ? <br /> � Oa a <br /> D <br /> Additional Comments: <br /> �►iv�' �rrP! res- <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 AMOUNT DUE AMOUNT REMITTED ECEIVE BY D TE PERMIT'NO. <br /> INFO / w"r'1 <br /> �H 1321 IAEV.I i A si 1I �/ r�v C/ f/ D/ 54 `� r� <br /> EH:4.26 /� <br />