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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f (Complete in Triplicate) <br /> Application is hereby, made to SanJoaquinCounty 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 18 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> y!f r <br /> Job Address +r r Ciry Lot Size/Acreage t�30 Y,3 X U- <br /> Owner's Name Address Phoney9z — 2 C <br /> i *` Address J License No./� s'�� Phone Z <br /> Contractor <br /> I TYPE OF,WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTAANLLATION ❑ SY TEM REPAIR ❑ OTHER O 4tonitoring Well U <br /> DISTANCE_;TO NEAREST: SEPTIC TKF SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION ` - AGRICULTURE ELL OTHER WELL PITS/SUMPS <br />€ INTENDED USE TYPE OF WELL PROBLEM AREA CON UCTION SPECIFICATIONS <br /> Cl IndustrialF].Open BoNom ❑ Manteca �- fWeM !excavation Dia. of Well Casing <br /> . * + <br /> 'ravel ack,fla C1 Tracy Ty of Casing Specifications <br /> I.1 Public [-1 Other '. T s Fl Delta Dep o[Gout Seal Type of Grout <br /> t rrigation # ce Approx. Depth I I Eastern Suri Seal installed-by <br /> I I <br /> Repair Work Done ! U Type of Pump .P.t St to a-Work Done_ <br /> ' f -1Ailing la rial i Depth <br /> Well Destruction D Weli Diameter' <br /> Depth �':__w._- t !'filler Material i Depth <br /> t E i .. 9 ter. - -.-. - ....-,.�...,.-...,...-... <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f .REPAIR/ADDITIONII I DESTRUCTION I 1 INo septic system perrtiitted if pitbiic Wwei We <br /> i ` / i availableiwithin 20D feet.) ', <br /> Installation will serve: Residence Cofnmercial i Other•._/ 1 -� ""3 ^= -y-�--." <br /> Number of living units: r Number of bedrooms <br />+ Character of soft to a depth.of 3 feet: ... ; -• Wster table depth • ¢ <br /> SEPTIC TANK. ❑ "Type 1%' Capeeity� Q No.-Compon nts4-- ) <br /> PK 16,. TREATMENT PLT. L1 {; I ---�-4�l� n Method of Di sal <br /> € aDistance tt nearest: Well 3�� Foundation r v / Property Line rt <br /> i t <br /> LEACHING LINE [1 No. & Length of lines T a1 length/size1 <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> I .M <br /> SEEPAGE PITS 11 Depth Site "' Njmb,r <br /> SUMPS Ll Distance to est: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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 lacus, Jnd�J <br /> rules and regulations of the San Joaquin'county t , t� <br /> Home owner or licensed agent's ikgnature certifies the following'"I—Certify that in the performance of•the work�,for which this permit is issued, t shall not <br />' employ any person in such manner as to become subject to workman's compensation 4w" sof Celifornia:'r,,Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which Okss permi <br /> it is ssued, I shall omploy'persons subject to workman's compensa- <br /> tion laws of California." # <br /> The applicant must call for all fired in tions. Complete drawing on reverse side. <br /> I •; <br /> Signed Title: N, !w C 1 Date: " F <br /> j f R DEPARTMENT OSE!ONLV }{ <br /> LPit ` �f�pication Accepted by .- —_' Date _ Area r Grout Inspection by ate ' Final Inspection b Dats��--"' <br /> Additional Comments: <br /> . Applicant - Return all copies to: San Joaquin County Public Health Services <br /> F Environmental Health Permit/Services <br /> t 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> AMOUNT pt1E AMOUNT REMl1TEU RECEIVED BY DATE PERMiT'NO. <br /> F INFO <br /> • EM 13.24IntiV.r/n5l r ro0 <br /> EN 1148 f <br />