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2 APPLICATION FOR PERI!I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 Servic <br /> Job Address 43 /L DYE'S City ZYA G Lot Size/Acreage <br /> Owner's Name MIDIV'29 Address Phone <br /> Contractor J&rh 0 5'-ON Address 400A ,Q L✓ %o4e- License No. Ft Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications W <br /> Il Public 1"1 Other n Delta Depth of Grout Seal Type of Grout Q <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Q <br /> Repair Work Done 0 Type of Pump H.P. State Work Done_ Q <br /> Well Destruction O Well Diameter Sealing Material • Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONX DESTRUCTION I I INo septic system permitted if public sewer is �1 <br /> available within 200 feet.) <br /> Installation will serve: Residence / Commercial_ Other <br /> Number of living units: _L Number of bedrooms I_ <br /> Character of soil to a depth of 3 feet: Water table depth %7p� O <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal ` <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size E <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth y Size X /rZ Number <br /> SUMPS J( Distance to nearest: Well AJO Foundation A-5­_ Property Line 3✓r <br /> DISPOSAL PONDS O 0 DH#LU.J/ eJ <br /> I hereby certify that 1 have prepared this 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 signature certifies 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 or subcontracting 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 compensa- <br /> tion laws of California." <br /> The applicant must call for all <br /> required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �'2" Area <br /> Pit or Grout Inspection by Date Final Inspection by a Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin P 0 Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AM/O/UNT RErMIIT�TED / K RECEIVED BY DATE l QPERMIT'N�jO. <br /> . EM 13-24IREV.iills) _ !! /. G�o !< �' L'c/ < `�J `7C� '2- 7 Z [2_ 6` <br /> EM 14.21 <br />