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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES l YEAR FROM DATE-ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application in 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. C <br /> Job Address I�r, <br /> S�OC A1V Lot Size/Acreage !3 l r"zrI <br /> . f f �it�y I_ <br /> Owner's Name U+ Aj f O N 17C E --__ r Address ?2 0- LIJ --- Phone Jz3 <br /> 1F_ J -D <br /> A5o1A1LL.1N _Address P <br /> ConContractor� c? � License No.d a14617 Phone Z/s;��3 ; <br /> - -— _— <br /> TYPE OF WELL/PUMP: NEW WELL`;!!�, WELL REPLACEMENT n DESTRUCTION 0 out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C10 ❑ Monitoring Well Y <br /> r � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Dl7 DISPOSAL FLO. PROP. LINE LA <br /> FOUNDATION _J f f _ AGRICULTURE WELL OTHER WELL _2013 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation _ Z _ Dia. of Well Casing .2 <br /> EI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Py L Specifications <br /> I'1 Public 171 Other IXDelta Depth of Grout Seal bEftffAA11.1t&AYpe of Grout L <br /> I I Irrigation ;L�]�.Approx. Depth I I Eastern Surfacs Seal Installed by Dieu u <br /> Repair Work Done U Type of Pump r, H.P. N)iff __ State Work Done <br /> Wali Destruction ❑ Well Diameter .Z Sealing 14aterial A Depth <br /> Depth '�'�, / Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) 1� � <br /> Installation will serve: Residence_ Commercial__-._ Other V <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line (� <br /> SEEPAGE PITS I ) Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats 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 fa 'ng: "I certify that in the perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of C ifornia." <br /> The applica st call for rsquir inspection „_Complete drawing on rave�e si G� <br /> Signed Title: .._T�.� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �' '�� Area <br /> Pit or Grout Inspection by Date in*) Inspection by oat r <br /> Additlonal Comments: <br /> Applicant - Return all copies to: San Joaquin Count Public Health Services <br /> Environmental He th Permit/Services <br /> 445 N San Joaqui , P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT RUE AMOUNT REMITTED I CK 8 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . Em13-24(NEN.I/x5) ��.� $ cSq.0a 2�c g.24y3 83_0275 . <br /> EH 14.20 <br />