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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUI4TY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAIL JOAQUIN, PHONE (209)468-$420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES I YEABBkSON DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1s hereby rade to San Joaquin County for a permit to conetrugt end/or install the vork herein described. This <br /> appltcatioa 1e R*de in cayliance vith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San,�„ A <br /> Joaquin county public Ifealth Stryiect. /�yy'l',,,, �q� <br /> Job Add+ess �4- /DJL�iYXJ� City Lot SlzelAcrease <br /> Owner's Name fl),!� Address Phone <br /> Conlracttx ,� � dress - License No. r' ? Phone <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> :Z— PUMP 1NSTALLATIO ))L-SYSTEM REPAIR W UJ454� OTHER ❑ monitoring Well p <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --�--- —�— DISPOSAL FLO. PROP, LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl bndustual <br /> D Open Bottom D Manteca Dia of WaN EKcavationo—��' Dig. 01 WaM Casing V s7 <br /> (-I Dorrnastic/Privets O Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> i"I Public �00����r R Oelt..i; Qepth of Grout Seat ---�riL'�T Typo of Grout <br /> klityation 3j/Approa. D l I EastlfA /4urfacs Saul InstaCwd by / <br /> Repair Work Done 'k Type of Pump H,P. �� State Work Done <br /> Welf Destnrction p Well Dismal" Sealing Material i *Depth <br /> Depth �l3' Tiller Material a Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADotT!ON i I DESTRUCTION 1 1 INC septic system permitted it public,sewer is <br /> available within 200 feet,) <br /> Inslallatkm wiN serve: Residence— Commercial_ other _ <br /> Number of living units: Number of ballrooms <br /> Character of colt to a depth of 3 foot: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capw.dy No. Compartments {� <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest Well_ Foundation— Property Line <br /> LEACHING LINE CI No. 6 Length of lime Total krlgth/si:e <br /> FILTER BED ❑ Distance to nearest; Well Foundation _ Property Line <br /> I <br /> I I <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS <br /> LI Distance to nearnt: Well Foundation prolerty Line <br /> DISPOSAL PONDS O 0 <br /> I hareby certify that I tm"prspsre4 this rpplicstion and that the work will be done in accordance with San Joaquin county ordinances, state lam, snd� <br /> rules end ragtlt 19wa of Ihs Sen Joaqulo County <br /> Homy owner or licensed agent"a signaiure ceniF"the for{owing: "'I cantity that in the performance of the work for which this parmil is issued, I shsli not r <br /> employ any person in such manner as to becorne su4*t to workman's compensation laws of California."'Contractor's hiring or sub-contracting signature <br /> coniflaa the following: '7 certify t7v t in the psrforMance of the work for which this permit is issued, I shall employ <br /> tion flaws of Cowornitl. ' parsons subject to workman..compsnsfo <br /> The appAeen er sir ctan.. Complete drawing on re-er sada. <br /> Signed Title: sClDate: L <br /> FOR DEPARTMENT USE ONL <br /> Application Accepted by Date . ~i"l '7E/ Arts <br /> Ph or Grout Uwpectio y Date Final Inspection by L. Det► r'/ <br /> Additwnef Cominart <br /> Applicant - Return all copies to: San JOaquin C unty Pub31c ealth Services <br /> Environmental <br /> OnHealth O 009 <br /> e ox 2 ,�i <br /> 445NSanJoaquin, Stkn, CA 95 1 <br /> 40a <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> PR - L 3. cK RECOVEt]Illy <br /> rrlln I F CASH PERCH 00Y5, F3—thl ,� <br /> YTSfr 11 �i�ni R /ruL: C <br /> P— 30' <br />