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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 a <br /> P O BOX 20092 STOC%TON, CA 95201 <br /> j <br /> PERMIT_MIRES 1 YEAR FROM DATE ISSUED <br /> l (Complete in Triplicate) <br /> _ r <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 /> Job Address ���;L �'O1_F t/1E_ft� An___ __ _ City L-0,00 Lot Siz Acreage <br /> Owner's Name YEA/X)AIS Address Phone <br /> Contractor E&QM 6, Weep License_No.__��XZ _Phone 5-3971 <br /> TYPE Of WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR -0 OTHER O Monitoring Well n <br /> 3_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER.LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> { <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom ' E] Manteca--- — Dia-of-Well-Excavation ,r Dia. of Well Casing <br /> fl Domestic/Private 0 Gravel Pack7 0 Tracy Type of Casing Specifications <br /> Public fl Other n-Delta Depth of Grout Seal Type of Grout <br /> 1 I Irrigation —.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 A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION DESTRUCTION l I (No septic system permitted if pubtic sewer is <br /> E, i available within 200 feet.) <br /> .Installation wilt,so"-."'Residence '� Commercial— Other Y <br /> Number of living units: Number"of bedrooms_ d <br /> Character of soil to a depth of 3 feat: Q y-�'f _ ____ Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg �X I s7iwl� Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ i. ti 't iI Method of Disposal <br /> Distance to nearest: Well Foundation Property Line 1 <br /> i <br /> LEACHING LINE LW No. 6 Length{of lines l- � _ _ Total length/size-- <br /> FILTER <br /> ength/size FILTER BED 0 Distance to nearest: Well-__�' �- Foundation -441"' Property Line _92?` <br /> SEEPAGE PITS t►r'Depth Zsr Size - � ` Number <br /> SUMPS . LI Distance to nearest: Well 60& L Foundation l irV�_ Property Line sd <br /> DISPOSAL PONDS 0 ✓ <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 /> 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 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 subcontracting signature <br /> certifies the following: "I 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 /> The applicant must call for alt <br /> required inspections. Complete drawing on reverse side. ; <br /> Signed >Li- .cf .LJSsy ___ _ Title: .,. X 3 <br /> Date: <br /> .'FOR DEPARTMENT USE ONLY <br /> f � f <br /> Application Accepted by Date 3 h, Area r <br /> Pit or Grout Inspection by Date .'s Final Inspection by Date 3 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Ruviroamental Health Permitlaervieee <br /> 445 N San Joaquin, P O Box ZO09, Stkn, CA 95201 <br /> FEECKAMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIY/NOO. <br /> • EN 13.24 IREV,tinst 1\ ' l/(Y — <br /> EN 14.26 t <br />