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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 /> 2 MIT EXPIRES I_YEAR ,rROM,,.DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct end/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, <br /> Job Address _—�� � /v �Q � � 72Z6 City gnr_,E Lot Size/Acreage <br /> J <br /> T Owner's Name MoW.44C Address _ Phone <br /> _ _ . <br /> Contractor 4 Address icense No.:��!1 Phone r <br /> TYPE OF WELL/PUMP. NEW WELL' WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ i <br /> PUMP INSTALLATIONk SYSTEM REPAIR ElOTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST., SEPTIC TANK SEWER LINES "��' DISPOSAL FLD. PROP, LINE <br /> 8 FOUNDATION _ AGRICULTURE WELL OTHER WELL -_ _PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dis, of Well Excavation 17-111' Dia, of Well Casing - <br /> ,*Domestic/Private .,Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Publics I'l Other ❑ Delta Depth of Grout­Seal Type of Grout <br /> M Irrigation ,, 3WApprox,'Depth L] Eastern 9urfaee Seal Installed by rte►` 4 <br /> Repair Woik-pone U Type of Pumper N.P. Z�:Z State Work•-Done <br /> Well Destruction O Well Diameter Sealing Material Depth t <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/AOOITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> available within 200 feet.) e <br /> Installation will serve: .Residence Commercial— Other S <br /> -Number of living unite Numbar'of bedrooms °� I <br /> Character.of soil'to a depth of 3 feet: Water table depth <br /> SEPTIC TANK r^O Type/Mfg. — Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 <" — -- Method-of Disposal ) <br /> Distance to nearest: Well Foundation Property Line ` <br /> LEACHING LINE 0 No. & Length o— f 1 e x Total length/size <br /> FILTER BED n ' Distance to nearest: Well r Foundation,— Property Line <br /> SEEPAGE PITS 11 ,Depth Size ' ' Number <br /> SUMPS 4•; �1. Distance to nearest-—Well - `Foundation Property Line li <br /> DISPOSAL PONDS 0. `% # f4 1 , <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, f shall not � <br /> employ any person in such manner as to become subject to wor4man's compensation laws of California." Contractors 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 mu a wired i Complete drawing on reverse .Oe: <br /> Signed x°-Thle ._' J .ice_ Date: 2 <br /> FOREPARTMENT USE ONLY 7 <br /> Application Accepted by Date 1 Area 2— <br /> Pit or60 Inspection by ate Final Inspection bye <br /> Additional Comments: <br /> Applicant R Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES '. <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES I <br /> 445 N SAN JOAQUIN; P 0 BOX 2009, STOCKTON, CA 05201 <br /> FEECK 11i <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. , <br /> . EH 13.24 IAEV. <br />