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3>� <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 13O% 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> R PM PATE-LUM <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address `� W- fit 1P It City Lot Size/Acreage <br /> Owner's Name r e ".W. Address J Phone <br /> Contractor t Address K License No. 212Lg19Z&_Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 )/OOT,,T,.,H����ER ❑ Monitoring Well E7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.&M-Ya. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS.___ r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI(%dS �I <br /> El Industrial ❑ Ppen Bottom ❑ Manteca Dia. of Well Excavati Lf Dia. of Well Casin <br /> Domestic/Private ravel Pack 'Tracy Type of Casing Specifications !� v <br /> ❑ Public ("I Other 0 Delta Depth of Grout Seaf1W i CZ Type of Grout ■rpal�+ftt7�� <br /> 0 tnigaiion Approx. Depth 0 Eastern Surface Sedl Installed by 4✓ 'p <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destructioni7 Well Diameter Sealing Material i Depth <br /> /1 Depth Filler Material i Depth AP <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G INo septic system permitted if public sews is <br /> available within 200 feet.! <br /> Installation will servo: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Wait Foundation Property Line <br /> ,- DISPOSAL PONDS 0 . a•- � - <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 fallowing: "I certify that in the performance of the work for which this permit is issued, I 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 following: "I certify that in the performance of the work for which this permit is issuedfM.alrall mmploy persons subject to workman's compensa- <br /> tion laws of California." C t <br /> The applicant scall f r all r ui d inspections. Complete drawing on to �rse,sidee. Cl <br /> Signed Title: ��� -JYC—P��y` Date: ���a� <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by Date d Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 3 /� <br /> Additional Comments: *' 12 l 2A r W e Q <br /> Applicant - Return all copies to: SAN JOAQU CO TY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 <br /> 1FEE AMOUNT DUE AMOUNT REMITTED CASH CK R/EECEIVED BY DATE PERMIT'NO. <br /> + EM 17.241ltEV.rinse {�1 1� M <br />