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APPLINATIOW FOR PERMIT r <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />/ ENVIRONMENTAL HEALTH DIVISION _. <br />445 N SAN JOAQUIN , PHONE (209)468-3420 <br />l <br />f P O BOX 2009, STOCKTON, CA 95201 <br />PERMIT FMIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />Application is hereby made to Ban Joaquin County for a permit to construct and/or install the work herein described. This <br />application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. i� ' //(/j(� <br />1-k AAA—. / 4, ivz .ls /�^7/A.!!�/// /FC�+l� ri..,//Y!/G'/� I.ot Size/Acre&m,3 V <br />Owner's Name P 1,v1/ t/� A(dressLicense <br />Address Phone /Contractor / �'F ` rot �vl/ No. ��� Phone <br />TYPE OF WELL/PUMP: NEW'WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well O <br />PUMP INSTALIATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK 2__ SEWER LINES LJGi�DISPOSAL FL PROP. LINE I� <br />FOUNDATION J216 d AGRICULTURE WELL �Oo OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />f_l Industrial O Open Bottom O Manteca Dia. of Well Excavation ) Dia. of Well Casl <br />Domestic/ Private Cl'Gravel Pack I -]Tracy Type of Casing_ Specifications <br />11 Public Cl Other rl Delta Depth of Grout Seal �� Ty of Grout <br />KIIrrigation Approx. Depth t I Eastern Surface Saul Installed by r <br />Repair Work Done U Type of Pump H. P. State Work Done <br />Well Destfuction O Well, Diameter Sealing Material & Depth <br />Depth Filler Material & Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 soll to a depth of 3 feet: _Water table depth <br />SEPTIC TANK O Type/Mfg < Capacity No. Compartments <br />PKG. TREATMENT PLT. O Method of Disposal <br />Distance to nearest: Well,_— Foundation _. Property Line <br />LEACHING LINE CI No, & Length of lines . _ Total length <br />FILTER BED Cl Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS 11 Depth _ Size Number <br />SUMPS LI Distance to nearest: Well __ Foundation �_-�Property Line <br />DISPOSAL PONDS ❑ <br />1 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 they 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 issued, I shall employ persons subject to workman's compensa- <br />tion laws of California." <br />The applica�tst st call al squired inapeetions. Complete drawing on r se side. <br />Signed -,...msµ i1 ��— Date: <br />Application Accepted by <br />PitGrout I pection by <br />Additional Comments: <br />Applicant - Return all copies to: <br />r EM 13.24 I REV. t/ AS <br />EH 14-26 <br />R DEPARTMENT USE ONLY <br />s�.b.eA.l Date. c,2 -'?n _�_.iZ_____--- Area oC, ` ` •. <br />Date < %� Final Inspection by ��^� Date ` <br />San Joaquin County Public Health'Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />11 <br />IEEE <br />AMOUNT DUE <br />AMOUNT REMI ED <br />CAST <br />Ill BY <br />DATE <br />PERMIT -NO, <br />T <br />11 <br />