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APPLICATION FOR PERMIT `% I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 1 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ' <br /> (209) 468-3447 <br /> PERMIT EMIR95 1 YEAR ?ROM RAIE ISSUED <br /> (Complete in Triplicate) i <br /> Application In 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. i <br /> Job Address�O io-;K r - ----- --- - City Lot Size/Acreage <br /> i <br /> Owner's Name Address _ _ - ----- Phone <br /> Conlraclor Addres�lil 1 4C/LiZ se 4 9.10-9 Phon <br /> TYPE OF WELL/PUMP-4- ,,,, ,,,,,r_NEW WELL ❑ __WELL REPLACEMENT_❑ DESTRUCTION ❑ Out of Service well Ll <br /> PUMP INSTALLATION{❑ SYSTEM REPAIR ❑ OTHER ❑ W Monitoring'Vell C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE /1 I <br /> { FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS v i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Ope `Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r <br /> U Domestic/Private ❑ Gr"! 'PackPack ❑ Tracy Type of Casing Specifications <br /> M Public, (I Other 0 Delta Depth of Grout Seal,' t"�' ; Type of Grout 1 <br /> C! Irrigation _.Approx. Depth 0 Eastern Surface Seal Installed by <br /> Repair Work Done L]..—Typsof.Pump. - ..._...-H.P._------- -- -State.Work Done,, <br /> Well Destruction 0 Well Diamoter Sealing Material & Depth <br /> Depth # Filler Material & Depth <br /> TYPE OFxSEPTIC WORK; NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 0 lNo septic system permitted if public sewer is <br /> available within 200 feet.) j <br /> Installation will serve: Residence-')L, Commercial Other' <br /> Number of living units: _-/— tNumber of bedroo <br /> Character of $oil to a depth of 3'feet: Water table depth _ <br /> SEPTIC TANK 40:57-0 Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ 4 _ __ Method oi.Disposal - - <br /> Distance to nearest: Well A Foundation Property Line <br /> LEACHING LINE No. & Length of lines Total length/size ° j <br /> FILTER Bio ❑ Distance to nearest: Well _ Foundation 242*0 Property Line' AL <br /> SEEPAGE PITS , , Depth � � Size Number f F <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL_PONDS-0.—A. �_. -- --w --w� -- - - � y --_., . � !,._w�..'A. ~r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county.q&dinances,-state laws,`and <br /> rules and regulations of the San Joaquin County -- - ► -(" I i <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is.issued,fshall not <br /> employ any person in such manner as to become subject In workman's compensation laws of California," Contractor's hiring or'sub•cont4cting signature <br /> Certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa-' <br /> tion laws of California." • , al* <br /> The ;ppficant II ar ell required inspa Ions Completed wing on versa side.Sign " TMoe2 Date: <br /> A., F EP ENT USE&ON LY" <br /> Appiicauon Accepted by Date r Area <br /> Pit or Grout inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: r <br /> t <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES + <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH FIECEIVE0 BY DATE P]EFIM17pNO, <br /> • EH Yl ,=$[REV.liS /�� �� , .f/"' / / ! ♦�� Y'lv/< 's r t <br />