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b <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION C <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ;• YEAR eM DATE IS§UM) <br /> (Complete in Triplicate) <br /> Application is hereby tirade to Saa'.Joaquin County for a permit to construct and/or install the vork 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 Services. <br /> Job Address .L' �3 fa �c,�rsf�lW(I•'4 City Lot Size/Acreage <br /> tj <br /> Owner's Namel1 " ! Address _1�" Phone <br /> ov <br /> _ <br /> ContiaciC AddreO_ A&1:4' t(�= Q-S 3 d License No 3��Z Phon �S�I <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT 17 DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 Monitoring'well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT: <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFitATIONS <br /> f] Indust isl ❑ Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing <br /> mastic/Private 0 Gravel Pack" 0 Tracy Type of Casing Specifications <br /> M Public 1-101 ❑ Delta Depth of Grout Seal Type of Grout l <br /> M Irrigation _.Approx, Depth 0 Eastern I Surface Seal Installed by <br /> Repair Work Done U Type of Pump_r� H:P,�, State Work Done <br /> Well Destruction O Well Diameter 1 Sealing Material i Depth <br /> Depth 't Filler Material R Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION G iNo septic system permitted if public sewer is <br /> 'JJ i <br /> available within 200 feet) �A7 <br /> Installation will serve: Residence Commercial Other [A7 <br /> A <br /> Number of living unite: Number of bedrooms <br /> Character of soil to a depth of 3 feet: .1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments X11 <br /> PKG. TREATMENT PLT, C] Method of Disposal 4� <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE t L'1 No. 8 Length`of-dines Total length/size J <br /> FILTER BED_ a r n Distance to nearsst:- Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth f ff Sire Number <br /> SUMPS Li Distance to nearest: i Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application arid that the work wil# 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 signawra canities-the iollawin�: "I canify that in the periorma6i a of the work for which tf�is 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 s gnature <br /> certifies the following: "I certify that in the performance of the work for which,this'permit is issued, I shali employ persons subject to workman's compansa- <br /> Ilon laws of California." y <br /> The applicant mu al fo+all required in petitions. Complete drawing on verse side. <br /> Signed <br /> Title Date: �Z :•_, <br /> y <br /> DEPARTMENT USE ONLY s <br /> Application Accepted by M1 Date —7/,//yArea <br /> Pit or Grout Inspection by Date Final Inspection d DaWe <br /> Additional Comments: f <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES _ <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT N0. <br /> INFO 44� <br /> . EN 17.26 IREY.r i n S! l�,� 7��,^ 7 L.'Sr 7 Z CG�Zcl�07 <br /> E►1 ;4.m � L w � ��cf/ <br />