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APPLICATION FOR PERMIT <br /> Z/ a f z ka a4Qdr yp-�2J pARe eL B <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> U /(j 2 k/,R-t--_1 ENVIRONMENTAL HEALTH DIVISION <br /> fsc n i c 's ;AJ �P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468w3447 <br /> Y R <br /> r d r✓ ,.("lete in Triplicate) �fSO- La <br /> A lirst to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cooapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> A6 <br /> Job Address City La� Lot Size/Acreage � _ <br /> Owner's Name ddress LX —S Phone <br /> Corntraetor Address 3S3 .Ltryolt-3 W" f License No.6-�7 Z- Phone 7iI20'49 <br /> TYPE_ OF WELL/PUMP: NEW WELL WELL REPLACEMENT C- DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION [D� SYSTEM REPAIR 0 OTHER 0 Monitoring well <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 /> M Industrialpen Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing O <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications .� <br /> � ('l Other 0 Delta Depth of Grout Seal Type of Grout <br /> l lrtlgation —Approx. Depth Eastern Surface Seal Installed by O <br /> Repair JV), one U Type of Pump H.P. ;.2 State Work Done _ 0�w <br /> Well:Destruction O Well Diameter sealing 16aterial i Depth <br /> i <br /> Depth Filler Material Ir Depth 2 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION ❑ 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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS IJ Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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 Calilornia." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work tot which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tlon laws of California." <br /> � <br /> The applicant mu call for all red inspections. Complete drawing on reverse side. <br /> Signed 7{ 1._ — Title: � 11 f 9 Data: <br /> EPARTMENT USE ONLY C� <br /> Application Accepted by Date L Area <br /> Pit or ro Inspection by " 'Date Final Inspection by 2',�/ �-� Date��� 4 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 H SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED By DATE (�PERMIT'NO.— 3 <br /> • EN t3 24(REV,. M5) v� f <br /> EN 1416 i 'O rrf <br />