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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 2ZMIT EXP1FWS 1 YEAR VROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application 1e hereby made to San Joaquin County for a permit to construct and/or inst&U the work herein described. This <br /> application In made in eo�tliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publics Health Services. 7 <br /> Job Address size/Acreage Ze C <br /> Owner's Name ZmileA" Address Phone ' —� <br /> • Contractor /� S �� �. <br /> Address c�l����/, q� Pte, icense No,=13 Phone — �? <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well p <br /> PUMP INSTALLATION, SYSTEM REPAIR C7 OTHER n Monitoring well L� <br /> DISTANCE TO NEAREST;•SEPTIC TANK 1Z,��� SEWER LINES DISPOSAL FLO. PROP, LINE ��'� <br /> 16 FOUNDATION �•/ AGRICULTURE WELL _Z 14-OTHER WELL PITS/SUMPSa20f-/- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open D Manteca - Dia, of Well Excavation 7. Dia, of Well CAaing <br /> � f/ <br /> A004stic/privAte .-Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M PHblic I:1 Other <br /> © Delta Depth of"Grout Seal Type of Grout <br /> Irrioation "-. 3WApprox;Depth, O Eastern �urfnca Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. f �'� a Stet3 lNoik Done _ <br /> Wall Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth :It.dil <br /> TYPE: OF SEPTIC WORK; NEW INSTALLATION f) REPAIR/ADDITION 0 DESTRUCTION Cl INoseptic 6ytilem permi4,ewnj.N. available within 200 feetInstallation will serve: -Residence�`• Commercial Other <br /> Number of living unit@; Numberof bedroomsCharacterof soil'to a depth of 3 feet: Water t@bte depthSEPTICTAN►{ YO Type/Mfg, �� ` Capacity No. CompartmentsPKG, TREATMENT PLT,0 - Method of DisposaDlstanc6'to nearest: Well - FoundatinProperty Line <br /> LEACHING LINE Cl No. & Length of f 1 s r ""� <br /> ` TotallangthJsize <br /> FILTER BED 0 ' Distance to nearest; Well ,Foundation' ` Property Line <br /> �. <br /> SEEPAGE PITS 11 ,Depth _�g17e _� Number <br /> SUMPS ';t 0. Distance to nearest: --Well.. . ' `Foundation <br /> Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work'will be donb io accordance with San Joaquin bounty ordinances, state laws, and`m- <br /> rules and regulations of the San Joaquin County ' �O <br /> Home owner or licenced agent's signature certifies the}Oflowing:"I certify that in the performance of the work lot which this permit is issued, I shall net it <br /> employ any person in such manner as to become subject to worMman's compensation laws of California."Contractor's hiring or sub"contracting signature <br /> cenifiss 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 Campensa <br /> tion laws of California." <br /> The applicant rn ,o timed i Complete drawing on reversarsi�fa: <br /> �f <br /> Signed X Date: 7- <br /> FOR EPARTMENT USE ONLY q <br /> Application Accepted by Oate 1 i , Area 2- <br /> Pit or res Inspection by ate r �� Final Inspection byq,,�.-1 <br /> Additional Comments: <br /> Applietu,t - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN; P 0 BOX 2009, STOCKTON, CA 85201 <br /> EEE AMOUNT DUE AMOUNT REMITTED C <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> . EH 17-21 <br /> EH IAEV.ii++6l rti <br /> '.4.26 <br /> q� <br /> ' �� P <br />