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' APPLICATIQN FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT let EXPIRES 1 YEAR rR DATE I§§_= <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 /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> city Size/Acreage <br /> A&W_Z_�7 <br /> Lot zecrege /r` � f.�'.-f�j�� <br /> Job Address <br /> —4Z oC 7 �-- <br /> �JS <br /> Owner's Name 'U dress _ Phone- <br /> Contractor <br /> honeContractor N s ddrass �f�— License No.111W 1 Phone <br /> TYPE OF WELL/PUMP: NtW WELLA WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION SYSTEM REPAIR C) OTHER ❑ Monitoring'Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL -- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom O Manteca Die. of Well Excavation ZVIDia. of Well Casing <br /> 11000mestic/Private Gravel Pack C7 Tracy Type of Casing G Specifications,. G�f <br /> * Public I'] Other ❑ Delta Depth of Grout Seal ��� _ Type of Grout. L— <br /> * Irrigation -;;�U Approx. Depth 0 Eastern Surface Seal Installed by �� I <br /> Repair Work Done U Type of Pump 1:W2 H.P. State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material L Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G (No 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 f <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ,SEPTIC,TANK O -Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLL 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ® No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE'PITS I I Depth• Si:e Number <br /> SUMPS ti` LI ;a Distance to nearest: Well Foundation Property Line <br /> DISPOSAL.PONDS '0r: <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 taws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or lilinssd agent's signature certifies the following: "I cartity 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 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 Celifornl <br /> The applicant u t r uir Complete drawing on revere ' e. <br /> Signed Title: Date: �f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by % Date Area <br /> Pit or Grout Inspection by � Date f Final In ection by Hate z� <br /> Additional Comments: ` �- is r U <br /> Applicant ^ Return all copies to: SAN JOAQUINICOUNfY PUBLIC HEALTH SERVICES �(Qf <br /> ENVIRONIKENI'AL HEALTH DIVISION PERMIT/SERVICES 0 <br /> 445 N- AN JOAQUIN,'P 0 BOX 2009, STOCKTON, CA 85201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEO CASH CK RECEIVED BY DATE PERMIT'NO. <br /> r EH 1).24tNEV.1/h31 '(13q r S� �k � IT00 a V <br />