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APPLICATION FOR PERI[I T <br /> SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES - <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> " .. (-Complete in-Triplicate) rry <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work 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. r� ,i. <br /> Job Address _4'72 2A � ��"�`� -- City Lot Size/Acreage <br /> Owner's Name" r`- VAIYIWIAddress Phone <br /> lIV 0 <br /> Contractor `udress � License No. < Phone �- <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OT E6 ❑ MonitoringWell ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP. LINE ; <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL 421 - PITS/SUMPS (� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation "Z Dia. of Well Casing 7 <br /> Domestic/private XGravel Pack ❑ Tracy- Type of Casing_ tSpacifications.. <br /> i'l Public rl O`s,��her35f n Delta Depth of Grout Seal �pQ- �� I Type of Grouter t <br /> I I irrigation �✓Appfox, Depth I I-Eastern t uriace Seal Installed <br /> by � � <br /> Repair Work Done U Type of P1imp H,P: "w_. "� -- Sta D <br /> Well Destruction ❑ Well Diameter 1,2 <br /> o Sealing Material.&-Depth <br /> Depth p Tiller.Material.& Depth, \� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I.W,REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is `! <br /> available within 200 feet.) <br /> Installation will serve: Residence e_Comirle'rcial_ 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ _ Method of Disposal <br /> is Distance�ta nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. S Length of linea Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation ? Property Line <br /> SEEPAGE PITS i I Depth Size - Number' ` <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> a <br /> I hereby canify 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 /> Hama owner or licensed agent's signature certifies the following: "l 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 compensa- <br /> tion laves of California." + <br /> The applieac f st roqui nsComplete drawing on raver side. / JJ ff <br /> SignedMeoi��itle: Date: ALL <br /> OR DEPARTMENT USE ONLe <br /> Application Accepted by Date _ Z Area <br /> Pit o �inspection by Date �`"� �� Final Inspection by Date <br /> Additional'Commantt: / l.f A' 3 �J <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> a -445 N San Joaquin,tP O Box-9009, Stkn, CA 95201 <br /> ! FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIVNO. <br /> r� <br /> . ' Inti~ f t /�, t t�t• _ad <br /> EH 13-24 IWEV.rie al — 31 <br /> 5 � rEH 14.20 / ! - <br /> �j <br /> �iSn /1W 1 4�/° <br />