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APPLICATION FOR PERMIT \ <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 /> nro� <br /> PERMIT EXPIRES I YEAR FROM DATE 13§PED No n <br /> (Complete in Triplicate) e-ta�1 <br /> Application is hereby made to Baa Joaquin County for a permit to construct and/or install the work here3nn �escre+d� his <br /> applicatian 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 * A&gt <br /> t Size/Acreage <br /> f� L Phone <br /> Owner's Name C H E "�O _ A s 64ry <br /> i <br /> r <br /> Conlractoil�lti�1�p RrE��CN -__Address � License N -Phone <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT n DESTRUCTION 0 out of Service Yell 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Mtonitering Well 0 <br /> DISTANCE NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> NDATION AGRICULTURE WELL OTHER WELL PS <br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SP S F <br /> * Industrial0 Open Bottom 0 Manteca xcavation Dia. of Well Casing <br /> * Domestic/Private 0 Gravel Pack 0 Tra Type of Casi _ Specifications <br /> 1'1 Public EI Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ox. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Type of Pump H.P. State Work Done _ k <br /> Wed Destruction ❑ Well Diameter Sealing Ifaterial A Depth <br /> Depth Piller Material & Depth � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION,I o septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence____. Commercial_.-,Other <br /> Number of living units Number of bedrooms i <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> ' r <br /> 4 Distance to nearest: Well Foundation. Property Line <br /> r4 <br /> LEACHING LINE 0 No. a Length of lines Totat length/size G <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I 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 applica t call r aduir i t' a. Complete drawing verse side. <br /> Signed Tide: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by O k.a.� M� .V ,_ .O flwk r•A Date a` - Area n <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Addhional Comments: - a--- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 +' <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> . EF1tINF1OJ CASH RECEIVED BY DATE <br /> qYPERM <br /> �NO <br /> 3-24IIEv. le0� v� —TLy. <br /> 1 <br /> 2S <br /> trt tats <br />