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it APPLICATION 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 /> 1 YEAR 0M <br /> (Complete is Triplicate) <br /> Application Is. hereby tmde•to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> potion Is made <br /> adeinompliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Jaquca <br /> ^� _. "3A ,,k,'1f 1F �b City Lot Size/Acreage <br /> Job Address <br /> r , R[]� ��oAddress7�, 5C? ' IC� Phone <br /> •Owner's Name _ <br /> 272 '61M t•. !.:' Phone <br /> • Contractor � - - r � .—License No. <br /> __. Address <br /> - = r-=a. WELL flEP-LACEMENT-17 DESTRUCTION LJ Out of Service well ❑ <br /> TYPE OF WELL/PUMP. -- NEW WELL OTHER ❑ Monitoring Well (� <br /> t �` PUMP INSTALLATION C) SYSTEM REPAIR ❑ I <br /> I <br /> b. DISPOSAL FLD, 120 POOP. UNE <br /> DISTANCE=-,T.O-N.EXREST:`SEPTIC-TANK���" SEWER-LINES ^ <br /> I'?_�,� FOUNDATION AGRICULTURE WELL _ OTHER WELL�� PITS/SUMPS,_ <br /> INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y k <br /> M Industrial ` Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing I� <br /> �T I Type of Casing, -- Specifications <br /> �gomestic/Private 0 Gravel Pack L7 Tracy <br /> .M Public f °� yfia-.Other p pelta Depth of Grout Seal Typa of Grout - - <br /> - .. t <br /> ru Irrigation �TApprox, peplh ❑ Eastern Surlace Seal Installed by <br /> `Repair Work Done L]"--Type of Pump H.P, State pone _ <br /> Well Destruction r"� G}---:-.Well Diamet <br /> Sealing ltstcrisl 'i` <br /> ry,�:. Ee Filler Materia i Depth <br /> Dept <br /> _ <br /> -TYPE OF SEPTIC WORK: NEW;.INSTALLATION D REPAIR/ADDITION CI.DESTRUCTION CI Ilio septic system permuted if public sewer is <br /> y` available within 200 feet.) <br /> } Installation will serve: Risidence.,_ ,Commercial T Other <br /> t Number of living units: Number of bedrooms <br /> ', Character of Goll to a depth of 3 feet: _ _ Water table depth <br /> SEPTIC TANK D Type/Mfg _ Ca_ citY� No. Compartments <br /> ,PKG. TREATMENT PLT.C� Method of Disposal <br /> 711 rstance to nearest: Well foundation Property Line <br /> u ; <br /> No. Length q s Total length/size <br /> LEACHING LINE ❑ g <br /> 'FILTER BED C:) Distance nearest: Well Foundation Property Line /7 <br /> SEEPAGE PITS l Depth Sim Number 5� <br /> SUMPS �. t I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL-PON � ..- <br /> I hereby comity 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 licensed agent's signature certifies the following: "I certify that in the periormance of the work for which this permit is issued, I shall not <br /> employ any porion 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 <br /> compensa-tion laws of Caldor <br /> r The applicant I spe mpleta drawing on reverse side. � <br /> L� /J�J.L1Jt/ <br /> Signed Title: �/� Date' <br /> r r ' FO DEPARTMENT USE ONLY q <br /> � f` � ._ <br /> Application Acce`pted by Date Area <br /> I. Date _ Dat 2 Dats <br /> ;Pit or Grout Inspection by a-�'� � Final Inspection by <br /> 'Additional Comments: _ <br /> 1i <br /> Applicant - Return all copies to: SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> j ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN. P O BOX 2049, STOCKTON, CA 95201 <br /> :FEE UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM11 NO. <br /> INFO <br /> + EH 134 (REV.r/n5i 2k_ <br /> EH <br /> r �I <br />