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. > <br /> 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 /> PER1dIT EXPIRES 1. YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Elan Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in node in ceetpliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of Elan <br /> Joaquin County Public Health Services. <br /> Job Address A-(4e'3.'- �� -V,5 �� City Lot Size/Acreage <br /> Owner's Name 2) a ,1C J��� Address — '54q21115 Phone <br /> t <br /> ContractorlA—JAl-L ) ddress "r r License No.43D 4�ai 2 Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR- ❑% OTHERI'D Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP.. LSINE <br /> FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial :❑'Open Bottom` ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications <br /> I'I Public n Other In Delta Depth of Grout Seal Type of Grout R, <br /> I I Irrigation , pprox. Depth�l 1 Eastern Surface Seal Installed by r �C✓� <br /> Repair Work Done ' 0 Type of Pump H.P. State Work Done V <br /> Well Destruction ❑ Well Diameter sealing Material i Depth I <br /> Depth Filler Hate -& Depth r ► <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i AIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence"1--fommeiciil Other <br /> Number of fiving units. --- Number of-bedrooms� <br /> Character of aoll to a depth of 3 feet , _....:-. Water table depth Az <br /> SEPTIC TANK &-4-vpe/Mfg 114 1 Capacity !/Lf)a No, Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation e v Property Line <br /> LEACHING LINE I - "� <br /> L�Iarb Length of lines Total length/size `r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line p' <br /> SEEPAGE PIT5Nymber <br /> Si", <br /> _ <br /> SUMPS L1 Distance to nearest: Well Foundation --, D Property Line <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 sub-contracting signature <br /> certifies the following: " rt ify that in the parlor e f the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> s,of Califom 4 <br /> The applic t II for am i ns a, on rev side. <br /> S - Title: Date: <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> "T Applicator i4ceeptad by - Data�l2- !3Area #� � <br /> Pit or Grout Insimfion by Date Final Inspection by Date <br /> Additional Comments: <br /> -T -- Applicant= Return,all copi*a-to:•- Ban•-Joaquin-•County Publi-c-Health Serviees- <br /> i Environmental Health permit/Services <br /> 445 N'San Jonquin,'P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. <br /> . EH i3-24 4t1EV.t i e 51 <br /> E � 0 0 l l ��r� 13Z <br /> M 1�•2a <br />