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APPLICATION FOR PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HE4LWVIC S� <br />ENVIRONMENTAL HEALTH D�V <br />445 N SAN JOAQUIN, PHONE (J0�� 3420 <br />P 0 BOX 2009, STOCKTON, �A <br />(Complete in Txiplica#1v# <br />Application is hereby viade,to San Joaquin County for a permit to construct aniE <br />application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and t erI <br />'Wft IBM - <br />Joaquin County Public Hea�l-thh Ser/vices. <br />Job Address �,.��� a S� (\\:�Ic City Lot 'ize/Acreage <br />,` 05 AN � <br />Owner's Name O Address a'7" Phone �14= <br />Contractor Address / 1/< W'G License Phone <br />TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service well 0 <br />PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 0 Monitoring well O <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — <br />INTENDED USE <br />C-1 Industrial <br />17:1 Domestic/ Private <br />VI Public <br />t I Irrigation <br />Repair Work Done U <br />Well Destruction ❑ <br />TYPE OF WELL <br />U Open Bottom <br />Ll Gravel Pack <br />n Other <br />— Approx. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br />0 Tracy Type of Casing_- Specifications <br />F-1 Delta Depth of Grout Seal RAYA - T <br />I i Eastern Surface Seal Installed by RrEGEIVE 1 <br />H. P. State Work Done _ <br />Sealing Material i Depth <br />Filler Material i Depths jr��llLNCOUNTY <br />NEW INSTALLATION I I REPAIR/ADDITION 1X. DESTRUCTION I I (No <br />Installation will serve: Residence Commercial X Other �' ~ •ww� <br />Number of living units: -kM Number of bedrooms <br />Character of toll to a depth of 3 feet: -- /W��ater table depth <br />SEPTIC TANK. � Type/Mfg _�!AL C paci1Y��A-o. Compartments <br />PKG, TREATMENT PLT. C1I,,�... Method of Disposal . <br />Distance to nearest: Well A4V� Foundation P57_ Property Line ZaL <br />Ir ..—L. - - l <br />LEACHING LINE 0 No. b Length of lines T rel length/size <br />FtLTER,BED . Distance to nearest: Well � Foundation /uProperty Line <br />X%� _ <br />SEEPAGE PITS I I Depth Size Number . <br />SUMPS Ll Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS ❑ <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, 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 tub -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 comp rnsa- <br />tion taws of California." <br />The applicant mu for all required tion Complete rewinq on r ide. <br />Slgned - Title: Date: <br />Q FOR DEPART T USE ONLY <br />Application Accepted by (✓`�..� Oate Area Z <br />Pit or Grout Inspection by Date Final Inspection by Data 1a <br />Additional Comments: <br />Applicant --Return all copies to: <br />Akzi <br />�L Z4? <br />EH 13.24 IIIFV. he st <br />EH 14-30 <br />San Joaquin County Public Health Services <br />Environmental Health Permit/Services <br />445 N San Joaquin, P 0 Rox 2009, Stkn, CA $20 1S <br />( O 0 /ti /,5 <br />FEE NFD <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT' NO. <br />I ��1 <br />��a3 <br />i� <br />12-1, <br />