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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 /> PEMIT1 YBAR <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or instei.l the work herein described. This <br /> applications is made in Coulpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publi <br /> c <br /> Health Services. J <br /> Job AddressIQ _U �2ee City L6d I Lot Size/Acreage <br /> Owner's Name Ka ll Address �� Phone le ' <br /> Contractor ­11 Add *�}`� License No= l�F-3 Phone ! <br /> TYPE OF WELL/PUMP: NEW WE L� WELL REPLACEMENT fl DESTRUCTION CI Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE L <br /> FOUNDATION —AGRICULTURE WELL OTHER WELLr20 PITS/SUMPS l <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS <br /> fl Industrial `Open Bottom D Manteca Dia. of Well Excavation O Dia, of Well Casing <br /> mastic/Private Cf Gravel Pack 0 Tracy Type of Casing t°e Specifications I <br /> l <br /> Pu lid I') OTPer 0 Delta Depth of Grout Seal - r Typ t Grout + <br /> V1r, awn �.�,,.Approk. Depth C1 Eastern Surface Seal Installedby.Work 15one C]—Type of-Pump H.P." State lNork Done_ <br /> ell D truction 0 Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPT1C WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION GI (No 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&oil 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 /> Distance to nearest: Well Foundation Property Line µ <br /> LEACHING LINE ❑ No. S Length of lines _ ,.c Total Iengthl.size--- <br /> FILTER BED n Distance to nearest: Well Foundation_ Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 - <br /> I hereby comfy 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 comifies the following: "l comity that in-thi 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 laws of California." <br /> The applicant must tali for all required inspections. Complete drawing on <br /> reverse side, t'^�fJ r`{—p9 <br /> S1gnsdr�_,r6(4-A- -W 6nLs, Tills: ,� �e Date: y r <br /> `—FOR-DEPARTMENT USE ONLY---- <br /> Application Accepted by Date Area — � <br /> PIR etion by•J Date( TZFinal Inspection b Date, <br /> Additional Comments: <br /> Applicant ^ Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 485 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 88201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED GASH 11 RECEIVED BY DATE PERMIT'NO. yw\ <br /> • EHt]•t41rtEV.riMs) A ,l`� a-^� L�.(,?—� q���� y • <br /> EN i4 �Vw �J'✓ 1 i <br />