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APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQIL DATE_„1$SUEU <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �” / City Lot Size/Acreage <br /> Owner's Name L & AddressPhone <br /> Contractor M s ="SAddresS License No. A&eFA19 Phone 7� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT/T DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR Cl OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES DISPOSAL FLO. f PROP. LINE l <br /> FOUNDATION f j AGRICULTURE WELL -Z= OTHER WELL V± PITS/SUMPS L> Q <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tl <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation- Dia. of Well Casing <br /> Domestic/Private Gravel Pack Cl Tracy 'Type of Casing_ Specifications <br /> I'1 Public Ia Other fl Delta Depth of Grout Seal JO/) Type of Grout <br /> I I Irrigalion C;�wApprox. Depth I 1 EasternSurface Seal installed by - - <br /> Repair Work Done U Type of Pump H.P. I State Work Done , _. fTJ �j ►. <br /> Well Destruction Well Diameter Sealing Material a Depth <br /> Depth �//J biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ( I DESTRUCTION [ I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: _ Water table depth o <br /> SEPTIC TANK. O Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to Clearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. b Length of lines_ Total length/sire <br /> FILTER BED ❑ Distance to nearest: Well Foundation y Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <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, anda� <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, 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 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 applican s c I lo all requi coons. Complete drawing on ro3 rt+o_side, <br /> Signed ills: "e_v—AData: _Z_- <br /> ��DEPSE,6/NTMI:NT ULYVAL, All <br /> , <br /> Application Accepted by Date, 1D Area <br /> Pit or Grout Inspection by Date g' S Final Inspection by Date <br /> Additional Comments: �1? 1. <br /> Applicant - Return all copies to: San Joaquin County Public Qa1th Services <br /> ]Environmental Health Permit/Services <br /> 445 N San Joaquin, 'P 0"Box 2009, Stkn, CA 95201FE <br /> INF AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMiT'NO. Q® <br /> . IM 13-24 ISEV:`1 016, <br /> 5i / ", V•. `-�► �. �. �j�G 11 <br /> f fEs4 14•1e ! �� IN 7 ,/Jfd <br />