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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERX1T EUI_MS I YEABBZAOM DATE IsgUED <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 /> applicatloo is rode in caipliance vitb San Joaquin County Ordinance No. 549 and 1862 And the Rules and Regulation* of San <br /> Joaquin County Public Heal <br /> th Services. �% / <br /> JohAdMesa vim ' L/OeE 42A ��� City�_ >�LSSaefAcrea6e <br /> Owner's Name Address !`�1!, , Phone <br /> Contractor dress ;�I16?0. /1- U License No.&;fer.rK Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION 0 Out of Service Well O <br /> 2_ PUMP WSTAiLATIO J)--SYSTEM REPAIR W lJ4" OTHER ❑ Monitoring Well L1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ice,_ OTHEA WrL1 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl IndustruCi Mamec <br /> t ❑ Open Bottom a Dia of WeN Eac_wation_ Dia- of Wall Casing d <br /> C 1 Domestic/Privmte Cl Gravel Pack ❑ Tracy Type of Casing_ �t SpscilicAtions <br /> V1 Public R Oelts Popth of Grout Sant r Type of Grout <br /> �- �/ <br /> I �lrripation 3 Appoa. D l I EntAAsUrtace Sail Insta!iad by <br /> Repair Work Done Type of Pump �tl`'' H '. State Work Done <br /> WON Destruction D Well Diaretar Bea-Zing Material A *Depth <br /> Deplh 2W !ffin� Tiller Material k Depth Le�1-�Y -:1:v'&I3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDIY!ON� I DESTRUCTION I % INo septic system permitted d public sewn is <br /> I <br /> available within 200 fest,) <br /> Installation will serve: Residence — Commerctat_ Other <br /> Number of kving units: Number of bedrooms <br /> Character of moll to a depth of 3 feat: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapWAY No. Compartments C,J <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well_ Foundation Property Line <br /> LEACHING LINE C1 No. Q Length of lines Tota) length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation _ Property Line <br /> I 4 . <br /> SEEPAGE PITS 11 Depth —Si" Number_ r <br /> SUMPS LI Ontance to nearest: Well Foundation _ Pro{:*rty Line <br /> DISPOSAL PONDS Q <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 t <br /> rules and regul.atwns of the Sen Joaquio County <br /> Horne owner or licensed agent's signature certifies the following: "I certify that in the performance of the work tot.Mich this permrl is issued, 1 shell not <br /> ampbY any person in such mermen is to become subtect to workmen's compensation laws of California."Contractor's hiring or sub-contracting signatute� <br /> certifies the following: "I cer,trfy that in the perfornurics of the work for which this permit is issued. I shall employ persons subject to workman's cornpenq• <br /> tion laws of Califorrda." <br /> The •police ae q9 coons. Complete drawing on re er•.aide. <br /> Signed �� Title: Date: C <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by Date Area ~ r At <br /> Phor OroUt Incpectio Dats Final Inspection by r Dsu � 3 <br /> 11 <br /> Addhionaf :omten%7t f S`p <br /> Applicant - Iteturn all copies to: San Joaquin C unty Pubic eelt.b Services.— <br /> E45 N San <br /> HealJoaquin, <br /> P Permit20Q9. ces <br /> Stk <br /> �L� 445 N San JoaQuln, P 0 Box 200th, 9tkn, CA 95 I tJ <br /> PR ` L13 IFFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 1!Y PEAM17 NO. <br /> �� <br /> 9� <br /> P „tr 1 -r 0 o0 6-l��s g3- �I f y <br /> 1 <br />