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' 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 /> PERMIT ESPIRES X YEARPRO_P.A19 15SUE <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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> T Job Address I City Lot Size/Acreage <br /> Owner's Name . ` � — �A ,Z _ Address ? &Z <�y?,�' � A*- Phone <br /> Contractor, 42lJ/fl ifs Address _T _5�4111e, - _ license No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 0 p Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL F PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 0TH ELL PITS/SUMPS r <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTI ECIFICATIONS <br /> n Industrial Cl Open Bottom ❑ Manteca 1 . Excavation Dia. of Well Casing <br /> CJ Domestic/Private ❑ Gravel Pack E3 Tracy ype of Ca A Specifications L <br /> M Public f-1 Other ❑ Del Depth of Grout Sea Type of Grout <br /> .� Da th astern 1ni dtion Approx. Surface Soul Installed b <br /> y (� <br /> j Repair Work Done ❑ Type of P H,P. State Work v 3 <br /> Well Destruction ❑ rametarI Sealing Material i Depth <br /> ' Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIR/ADDITION 0 DESTR41CTION <br /> ;%I No septic system permitted if public sewer is � <br /> )( vailable within 200 feet) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: _115L Number of bedrooms_ � <br /> Character of soil to a depth of 3 feet:� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg, Capacity 7 No. Compartments <br /> PKG. TREATMENT PLT.❑ 1 Method of Disposal <br /> Distance tat,nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size }� <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line (J <br /> f <br /> SEEPAGE PITS 11 Depth 1 Slee Number <br /> SUMPS Cl Distance to.nearest: Well Foundation Pro Line <br /> Property <br /> DISPOSAL PONDS ❑ i <br /> I hereby certify that I have prepared chis,application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signatures cenifies the following: "I certify 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 of subcontracting signature <br /> certifies the following: '9 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 California." I <br /> The applicant must _It for�a11 squired inspections. Complete drawing on reverse side. + t <br /> 'Signed Title: _ �1�� Date: 1'`2 <br /> FORPEPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: —_i'._ r(c`s s o ! a +r4 Z <br /> Applicant = Return all copies to:' SAN'JOAQUIN COUNTY PUBLIC HEALTH SERVICES ckri,)r fro"'�~e " p'e� s <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES V <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STUCKTON, CA 95201 <br /> INFOFEE AMOUNT DUPE ' AMOU`N�T REM�iTT/E�D CASCK H RECEIVED SY DATE r PERMIT'NO, <br /> • Eli 14-M f <br /> IREV.r�n Sl �A. <br /> '{•2a <br /> EM . f Y e, ���'�l � rQ, <br /> �l <br />