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7 AV- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3 `� P'l <br /> ENVIRONIMTAL ffEAT.Tg DIVISION - <br /> 445 N SAN JOAQUIN, .PHONE (209)468-3420 `'f-��-9 2— <br /> P O BOX 2009, STOCKTON, CA 95201 _r <br /> PERMIT E%PI �� 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby msde�t:o San Joaquin County for a' <br /> Permit}to construct and/or install the work herein described. This <br /> spplication is atede in compliance with San Joaquin county`Urdinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ` �/� NO- <br /> Job <br /> ► <br /> Job Address �/o(A� �l l4>h ����L� i✓ City Lot Size/Acreage <br /> Owner's Nems _{d1/,A:— <br /> Address Phone <br /> Contractor ( �// 0e&2�irdress 3 S to., I• Phone 9 <br /> TYPE Of WELL/PUMP: NEW WELL C! WELL REPLACEMEN DESTRUCTIONL7KQut of Service Well ❑ <br /> PUMP INSTALL�ATrI�O,N.�-C1 SYSTEM REPAIR ❑ OTHER C1 Monitoring Well ❑ j <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPUSAL FL <br /> FOUNDATION <br /> LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> t <br /> INTENDED USE TYPE OF WELL wv PROBLEM AREA CONSTRUCTION SPECIFtCA IONS <br /> M industrial ❑ Open Bottom O Manteca Dia. of Well Exc vati, IlWa Dia, of Well Casing <br /> ,�td.pomesticlPrivate C&Gravei Pack ❑ Tracy Type of Casing /SpecificationsS <br /> I'I Public t7 � [ y Dale Depth 1 Grout Seal :��Tr1��.t'� Type of Group <br /> i i Irrigation rte:..gg t'ft'Efil �' <br /> tD ppr x. Depth n Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. i— 4 <br /> Wall Destruction ction Well Diameter Sealing Material i Depth - <br /> Depth -07Z .Mlles Material i Depth ,t �jL4—Zf .: <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitted if public sower is <br /> available within 200 feat.) t <br /> Installation will serve: Residence_._ Commercial— Other + M~~ <br /> Number of living units: Number of bedrooms r t <br /> Character of soil to a depth of 3 last: Water table depth <br /> SEPTIC TANK. ❑ TypelMfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT.❑ Method of Disposal y <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE ❑ No. b Length of linea Total length/size <br /> FILTER BED Cl Distance to nearest: WeII <br /> Foundation Property Line i <br /> i•1 I <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS ! <br /> Ll Distance to nearest: wall Foundation Property Lina <br /> DISPOSAL PONDS Q T <br /> I hereby certify that 1 have prepared this appkcation and that the work will be done in accordance with San Joaquin county ordinances,irate laws, and <br /> rules and 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 permt is issued, I shall not �I <br /> employ any person in such manner an to become subpct to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> following:canifies the "I certify that m the performance of the work for which this permit is issued, I shall smplOy persons subject to workman's compensa- <br /> tion taws of n <br /> The s t s f all <br /> _ r • r n 'i , pons. Complete drawing on r so side. c1.---- <br /> Signed , <br /> Title: �— Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by ! f <br /> Date <br /> Pk G t nspection Date Final Inspection b d � Data <br /> Additional CommentsZ -1 <br /> j¢p 11 a �R e urn llcopies to: San Joaquin County Public Health Services �t O k <br /> (��j� Environmental Health,Permit/Services s <br /> amsf <br /> Sa J nq in, P O tax 2 , S nCA 5201 � �AMOUNT REMITTED CK RECEIVED AY OATS PERMlY'N0.i L4- <br /> EN ICU CASHi �( q 4� •) <br /> s - <br />