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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> Cq- © P O BOX 2009', STOCSTON, CA 95201 -0/ <br /> (209) 468-3447 <br /> Y PRQM PATH ISSUED <br /> (Complete in Triplicate) 2I <br /> E-m c-ovt }+cam <br /> Application is hereby made to 3 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. 5ftand 1662 and the Rules and Regulations of San <br /> • Joaquin County Public Health Services. <br /> Job Address LO S' U7 RaN �___ City Lot Size/Acreage <br /> Owner's Name CJ cc Address Phone <br /> Contractor Address 29_2S License No. S(zIkLE� -- -Phone AqE 13 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'X onitoring Well €� <br /> of�.[►JGS <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. R9Q4­Lrl*Ef <br /> FOUNDATION AGRICULTURE WELL OTHER WELL RkSESt}MPB .r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tt htlCtt0. <br /> i7 IndusUial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> (J Domestic/Private ❑ Gravel Pack C1 Tracy r Type of Ca >� <br /> M Public I'1 Other © Delta Depth of I i3O '�30 Type-af 6rvclt <br /> Y t <br /> �J Irrigation �._..Approx. Depth 0 Eastern y / W <br /> Repair Work Done U Type of Pump H.P. WOPIC 9 FW <br /> Welt Destruction O Well Diameter Sealing Material III Depth Wk-1 12JA 7, 4 Di2ta4 <br /> Depth Tiller Mate: 6w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is M <br /> available within 200 feet.) <br /> Installation wilt serve: Residence r. 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 ® No. & Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest, Well Foundation 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 fallowing: "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 subcontracting signature <br /> certifies the fottowing: "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 Cali rnia." <br /> The applicant _I <br /> caH foretl tequire i p@ctions. Complete drawing o ver ids. I� <br /> Signed [� Title: Date: <br /> _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r t— Area _ZI7 <br /> Pit or Grout Inspection by Date Final Inspection yDate 1 � 42 <br /> 94 Additional Comments: s^ <br /> IV 9 <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O B9XJ049, STOCKTON, CA 95201 nil <br /> FEE <br /> )NFO AMOUNT DUE AMOUNT REMITTED CKSH RE EIVED BY p TE PERMI7'NO. <br /> . EHr3-74111EV. sl / �� /� �U✓ lv ��/ <br /> EH'l•26 � <br />