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APPLICATION FOR PERM <br /> SAN JOAQUIn COUNTY PUBLIC H�TC <br /> ENVIRONMENTAL HEALTH DI <br /> 945 N SAN JOAQUIN, PHONE (20 4-1 <br /> P O BOX 2009, STOCKTON, C <br /> PFMIT EXPIRES I YEAR FROM aa���—_ <br /> (Complete in Trip licattv to <br /> Application to hereby ssule to San Joaquin County for a permit to construct and/or install the vor s <br /> application is zxde in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rule• and Regulations of Sen <br /> Joaquin County Putlie Health Borvices. <br /> Job Address r � Ci1yC ajt. Lot site/Acreage CUAZ <br /> Owrlei s Name "1 r.yv1.rYll'� Address _ _'J "�1h L� Phone <br /> Contract r�� G►. �7L�. <br /> C�7 Address � ��n L `License No.�`J` a`�'Phone 6 'J S IBJ <br /> TYPE OF WELL/PUMP: i1,JEW WELL D WELL REPLACEMENT Cl DESTRUCTION Cl Out of Seryice Hell 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O )fonitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Q Open Bottom ❑ Manteca Dia. of Well Excavation_ Ois. of Well Casing <br /> Ci Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing_ Specifications <br /> I'I Public r'1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal invii4sed by l!� <br /> Retook Work Dont LJ Type of Pump H.P. State Work Done 1 <br /> Well Destruction O WON Diameter Saa_ling 11at:orial i Depth MJ <br /> DepMaterial i, Depth �/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I kkgAiRPADDT15DESTRUCTION I I INo septic system permitted if public sewer is <br /> / available within 200 I"t.) <br /> Inits4etion wilt serewa <br /> : Rerice� Corrlrrlerciaf Other <br /> Number of wing units: �_ Number of beekooms <br /> r <br /> Chwacter of sob to a depth of$low: Water table depth <br /> SEPTIC TANK D Type/Mfg I y" Cal�a:.ity No. Compwtments <br /> PKG, TREATMENT PLT.L1Method of Disposal OtJ <br /> i O*t&nce to nearest: Well _ Foundation T Property Line <br /> ©O t r <br /> LEACHING LINE No. i Length of Ik»s , OO X <br /> ng t Total bngth/site r <br /> FILTER BED ❑ Distance to nearaat: Well ' Foundation G r _ Property Line S <br /> SEEPAGE PITS I l Depth Si» Number_ <br /> SUMPS LI Distance to news": Well Foundation Property Line <br /> DISPOSAL PONDS Q <br /> I hereby sonify that I have prepared this opplieation and that the work wig be done in accordance with San Joaquin county ordinances, slate taws, and <br /> rules and ragulaliona of the San.losqu,rl cmwty <br /> Home owner a licensed agern's signature certifies the foAamng: "I certify that in the performance of the work for which this pwmt is issued, I shall not <br /> emploY any Berson in such manner ru to become subject to workman's compensation Laws of California,"Contractor's hiring or sub-contracting signature <br /> canities the forowing: "I cartify that in the performance of the work for which this permit is issued, I$hall employ persons subject to workman's compensa- <br /> tion Tawe of CaMornis.'. <br /> The applicant t CAN for or required inspections. Complete drawing on rove+se Vie, <br /> Slgrwd Title: ` <br /> Date: <br /> �- FOA DEPARTMENT USE ONLY <br /> Application Accootod by Date - Area f <br /> Pit or Grout Irrpectbn by Date Final Inspection by ata v1_1/ I /� <br /> Additional Comments: \ I(( <br /> APrllcant - Return all copies to: San Joaquin County Public Besltb Bervlce§ <br /> Environmental Health permit/Services <br /> / 445 h San do aqu Box 2o09, Stkn, CA 9 01 S <br /> !/ FEE AMOUNT DUE AMOUNT MEM1 7ED v <br /> K RECEIVED BY PERMIT'NO. <br /> INFO N "f/] <br /> EH 14-20 ` <br />