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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEAL VIC S <br /> r <br /> ENVIRONMENTAL HEALTH DIV �rnlmrr <br /> 445 N SAN JOAQUIN, PHONE (#%V 3420 <br /> P 0 BOX 2009, STOCKTOA A <br /> PERMIT FXPIRES j, y jDF <br /> (Complete in Tripl.icai1v# 15�� <br /> Application is hereby made to San Joaquin County for a permit to construct an - <br /> 4011CAtion is made Sit c-Pliance with San Joaquin County Ordinance Ho. 549 and 1862 and is <br /> Joaquin County Public Health <br /> Services. <br /> Job Address 025 ��dql} ,51SPCity Lot '12e/Acreage <br /> 1 /� SAN rnP� <br /> Owner's Name -- <br /> _ - /! t/ (>S� <br /> Address 'SG�L Phon ig�-/5�44.2 <br /> � �i' �j/r L sora w�Y <br /> Contractor / r�Address s License tVr,�'�1Sphone <br /> TYPE OF WELL/PUMP; NEW WELL M WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR El 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 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> P Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Oomestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ S Ifications <br /> Il Public I"1 Other Fl Delta Depth of Grout Seal AYMENT <br /> t I Irrigation —Approx. Depth I I Eastern Surface Seal Installad by _ CflG1'sCltill�tCr <br /> Repair Work Done U Type of Pump H.P. State Work Done- L VE-CT <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth J — <br /> Depth Filler Material i Depth raved Itual IIN rOUN 'Y <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo sseem�i <br /> avatlarl �. s <br /> Installation will serve: Residence— Commercial Other <br /> Number of tieing units:-,�L& Number of bedrooms -�(a <br /> Character Of sol to ar <br /> depth of 3 feet: �/W�-ater talars depth <br /> C-14 <br /> SEPTIC TANK X, Type/Mfg _` �- pacity Compartments <br /> PKG. TREATMENT PLT.Q Method of Disposal <br /> Distance to nearest; Well f "Foundation /,!E5- - Property Line-sC-a: <br /> LEACHING LINE 0 No. &Length of lines T ref Is <br /> FILTER�B D Distance to nearest: Well es 1 Foundation ��SProperty Line 1_ <br /> i <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Lt Distance to nearest: Well Foundation Pro <br /> DISPOSAL PONDS ❑ t'e►tY Line <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, and <br /> ruies and regulations of the San Joaquin County <br /> Horne owns►or licensed agent's Signature certifies the following: "I certity 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 fallowing:"I certify that in tete performance of the work for which this par-A is issued,I shall employ <br /> tion laws of California." p v parsons subject to workmen's Compensa- <br /> The applicant mu for all nqu tion . Comgjete rowing on r ide. -*-7 <br /> Signed <br /> Title: Date: <br /> R DEPART T USE ONLY <br /> Application Accepted by <br /> ✓�+t/�. FO <br /> Date Area Z <br /> Pit or Grout Inspection by Date— Final Inspection by ddL Date 1S <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health services <br /> AdTtt1� Bevironmental Health Permit/services <br /> f"� 44S N San Joaquin, P O Box 2009, Stkn, CA $201sleo 06115 <br /> FEE AMOUNT DUE AMOUNT REMITTED r) (1 CJtJ <br /> Z <br /> NFO CASA RECEIVED 0Y pATE AEAMIT'NO. <br /> . EN13.14IIIFY.ir�6i <br /> EN 14-711 <br />