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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> (Complete in Triplicate) <br /> Application is hereby Stade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ccupliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address —IQV `� City Lot Size/Acreage <br /> Owner's NameAddress qzFu Phone <br /> /� _ r ?. -960 <br /> T �--•.'� � <br /> n <br /> Contractor Address k License NO. Phone 172,r 0 <br /> TYPE DF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well t3 <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 /> Cl Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing S <br /> M Public t"1 Other Specifications <br /> ❑ Delta Depth of Grout Seal _ Type of Grout r ,,� <br /> M Irrigation _.App(ox, Depth El Eastern Surface Seal Installed by _14�T V1 <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION ID REPAIR/ADDITION DESTRUCTION CJ (No septic system permitted if public sewer is <br /> Installation will serve: Residencex Commercial,,,,, Other available within 200 feet.) <br /> Number of living units: Number of bedrooms 2— <br /> Character <br /> Character of soil to a depth of 3 feet: Water table depth lQ <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, O <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines - 97 Total length/size <br /> FILTER SED [I Distance to nearest; Weil � Foundation Property Line <br /> SEEPAGE PITS ,qr Depth Siza Number <br /> SUMPS CI Distance to nearest: Well <br /> DISPOSAL PONDS E] ,Foundation , Property Line <br /> I hereby certify that I have prepared this application and that the work LWifl be done in accordance with San Joaquin county ordinances, state Iaws, and <br /> rules and regulations of the San Joaquin County <br /> Home owns(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 sub-contracting 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 compansa- <br /> tion laws of California." <br /> The applicant m bit for all r re�spections.,Complete drawing on reverskaide, <br /> Signed Title: YT <br /> D&te: _&-_2/- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by72:� <br /> Date � 0 Area �- <br /> Plt or Grout inspection by Data��,-, Final Inspection by—�� <br /> -�.�. 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 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMpUNT REMrTTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> . <br /> EH 13.24 MEV.i i n yr °rte_ r <br /> EH t�•2a f��u / /qg <br /> 7� V w3o$ <br />