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APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> .PERMIT E%PIRES I YEAR FROM DTE ISOM �j <br /> (Complete in Triplicate) I� <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in 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 /> Job Address is- <br /> �� .._.._ —City-- Lot�b�iz%crea8e ' <br /> �`" ev �tlFl = �r Phone <br /> Owner's Name 2—/ ' dress <br /> Contractor// ® Address License No.� _Phone W3� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ["1 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATI N�; SYSTEM REPAIR ElOTHER ❑ MonitoringWell ❑ <br /> DISTANCE TO NEAREST: SEPTIC%TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> "i FOUNDATION AGRICULTURE WELL = OTHER WELL -PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial F ❑ Open',Bottom ❑ Manteca 'e Dia. of Well Excavation F Dia, of Well Casing <br /> Domestic/Private ravel Pack 0 Tracy ' Type of Casing Specifications <br /> Public• [I 01her 1'1 Delta Dept of Grout=Saab: __ - l Type of Grout <br /> ALApprox, Depth���IJJ,IIE�Ea�sterrj" 5u¢ ce Seal Installed by w..OQJ4591 1-5— Mx <br /> t Repair Work Done ❑ Type of Pump ��'�, FI.P. `4 State Work Do n-'6` ' <br /> Well Destruction El Well Diameter Sealing Material i Depth <br /> Depth Filler Naterial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available-within 200 feet.) <br /> Installation wHl.serve: Residencm— Commercial T Other <br /> Number of living units: Number of bedrooms /1 <br /> Character of soil to a depth of 3 feet: r -- Water table depth <br /> i SEPTIC TANK, ❑ Type/Mfg,1 Capacity No. Compartments <br /> PKG. TREATMENT PLT.,❑ .4 Method of.Disposal <br /> T Distance to neorett: " Well Foundation Property Line 1 <br /> a 5 <br /> LEACHING LINE L1 No. b Lengthofline's * Total length/size � <br /> FILTER BED ❑ Distance to nearest; Well Foundation Property Lina <br /> SEEPAGE PITS I 1 Depth Size "'��"' Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lin* <br /> DISPOSAL PONDS ❑ <br /> t I hereby certify that 1 have prepared this application and thatytlii work will be done m accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San JoaquinlCounty' <br /> Home owner or licensed agent's signiiture 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 or sub-contracting signature <br /> certifies the following:"I certify that in-the p°rformance of the work for which this permii is-issued, I shall employ persona subject to workman's compensa- <br /> tion laws of CaliforMs." <br /> The applicant for all r tions Complete drawing on,rever side. + �. <br /> f Signed Title: Date: <br /> ti <br /> �7 A FOR PARTMENT USE L LY <br /> Application Accepted by r <br /> 1Date 9 Area <br /> Pit G►ou specticn by Date 1 Final-Inspection Z&JIVIIX Date /D <br /> -Additionil_Co i�hti: - �l'� fhe <br /> � <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> I' 445'N-6an Joaquin,-P O B6x-2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED x RECEIVED BY DATE PERMIT'N . <br /> INF <br /> Lu AJ_L� <br /> EH 13.24(NEV,I R er l� I ' / <br /> Err 1420 <br /> _�i <br />