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APPL I CACTI ON FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> X11 /�f P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 {x, <br /> ZEMIT IRES 1 Y&AR rgom DATE <br /> (Complete in Triplicate) <br /> Application is hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ealthianceSery with San Joaquin�un Ordi n N and 1862 and ttre and Regulations of San <br /> Joaquin County Public Health Services. �� l <br /> '[ Job Address City Lot Size/Acreage <br /> 7-4-h" 01,Ws ,liscrc r. �} <br /> Owner's Name Address C,?r/��C3 /C/ � .4/.n ._ Phone �\ <br /> Contracts Address License No. Phone <br /> TYPE OF WELL/PUMP, _ y_ NEW WELL ❑ WELL REPLACEMENT _ DESTRUCTION Out of Service Well Cl <br /> PUMP INSTALLATION ❑ _t SYSTEM REPAIR ❑ OTHER•❑ -Monitori-ng. Well <br /> DISTANCE'Ft] NEAREST`SI:PTTCTANK PRflP?klfVE -- -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP F WELL PROBLEM AREA CONSTRUCTION SPECIFICATI �� ��- <br /> f� Industrial pen Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing Q <br /> U Domestic/Private M Gravel Pack 0 Tracy Type of Casing Specifications <br /> ' <br /> u Cl Other ❑ Delta Depth of Grout Seal Type of Grout c}► <br /> {� rri aeon f <br /> tl _.Approx, Dept ❑ astern Surface Seal Installed by. <br /> Repair wok U Type of Pump H.P. State Uvork o _- <br /> ell Oestrut+tion ell Diameter _ Sealing Material & Depth <br /> pth Filler Material & Depth <br /> TYPE OF RIC; NEW INSTALLATION JO REPAIR/ OITION L"! DESTR TfON G iNo 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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg apacity— No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ound 'on Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size umber <br /> SUMPS LI Distance to nearest: W ,_.,. Foundation <br /> Property Lina <br /> DISPOS"AL-PONDS -""T]-- <br /> rules and regulations of the San Joaquin County - <br /> I hereby certify that I have prepared this application and that the work wi$l be done in accordance with San Joaquin county ordinances, state laws, and <br /> -__ <br /> Home owner or licensed agent's signature certifies the following: "1 certify that irl the performance of the work for which this permit is issued, t shall_not—F <br /> employ any person in such manner as to become subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I unify that in the performance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa• <br /> tion laws of California.,, <br /> The applica t at ail for all r d insqitictiong. complete drawing on rose side <br /> Signed T T _ I ! <br /> Title' Da .r9- l <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by bate r / Area .7/ <br /> Pit orL/ t Inspection by <br /> L/ ate Final Inspection by Date > <br /> Additional Comments: � <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 2008, STOCKTON- CA 68201 <br /> FEE AMOUNT ptJE AMOUNT REMITTED CK J <br /> INFO CASH RECEEVEO 8Y DATE-T NO. `vJ <br /> EH 13.24 fREV. <br /> EH 1t,•as <br />------�— <br /> 17.t.04Y9!, Yeo <br />