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APPLICATION FOR PERMIT M <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 0 Q <br /> ENVIRONMENTAL HEALTH DIVISION 1V FCJN-cJ� <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 458-3447 <br /> k6- <br /> PERNIT .BMIR SEAR_ �M DATE IblaVED <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 in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> l 3 ILC `S City Size/Acreage <br /> + /Job Address ����-�rLl__ Lot Sire/Acre e <br /> Owner's Name (AftK SCffLW Address o Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> U Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing Specifications <br /> R Public Cl Other © Delta Depth of Grout Seal Type of Grout <br /> G Irrigation Approx. Depth M Eastern Surface Seal Installed by w <br /> Repair Work Done LJ Type of Pump N.P. State Work Done _ <br /> Well Destruction O Wolf Diameter Sealing Material 6 Depth <br /> Depth Filler Material & Depth <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR IADDITION Cl DESTRUCTION I (No septic system permitted it public sower is �] <br /> available within 200 feaLl <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living unite: Number of bedrooms <br /> Character of toil to a depth of 3 feet: Water table depth <br /> I SEPTIC TANK .❑ Type/Mfg Capacity No. Compartments <br /> ' PKG. TREATMENT PLT.❑ Method of Disposal <br /> I <br /> Distance to nearest: Well Foundation Property Line <br /> F LEACHING LINE CI No. & Length of lines Total lengthtsize <br /> FILTER BED [I Distance to nearest: Walt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Welt Foundation .Property Line <br /> DISPOSAL PONDS .. ❑ <br /> w 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 /> F rules and regulations of the San Joaquin County <br /> k 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 shell not <br /> I 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: 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> KTho <br /> applicant must call for all required inspections. Complete drawing on reverse side <br /> Signed X C� --s�l��'/�-O�'� _ _ Title: Dw�t ec Date: `1 <br /> !��FMODEPAfLTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date a <br /> 3 Z7d <br /> Additional Comments; _ <br /> Appli bat - Return all. copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> Y 495 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO MOUNT DUE AMOUNT REM3TTED �jCASH RECEIVED BY DATE y�PERMII'NO. <br /> r EK 13INtsV.I/" <br /> t -7 G-10 <br />