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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT, EXPIRES_I SEAR FROM M DATE I5599D <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cam�liance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. a� <br /> Job Address _ �� I�0 �� �a r~ l�� City Lot size/Acreage C Q Gt'c- <br /> Owner's Name f,1"��,1� ICA 6 h IN Address ca 0F V� a L-41&3,6 it ,' LrlPhone <br /> Contractor �� Address �� License No. <br /> a� �� Phone <br /> TYPE OF WELL/PUMP: N tW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C❑ Out of Service well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 Monitoring I Well <br /> K <br /> DISTANCE TO NEAREST: SEPTIC TANSEWER LINES DISPOSAL FLO. PROP. LING-2Q''ti�� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPSii't=l° <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> ❑ Public lel Other 0 Delta Depth of Grout Seal Type of Grout 4 <br /> r rngation = Approx. 0 pth Iu Eastern ice Soul Installed by <br /> Repair Work Done ' Type of Pump n e H.P. / '�^ State Work Done _ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Piller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LI REPAIR/ADDITION 0 DESTRUCTION El (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 soil to a depth of 3 feet: Water table depth t <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 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Propeny Line tJ.. <br /> SEEPAGE PITS 11 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 taws, 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 following: "I certify that in the porformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." c. <br /> The applicant must call for all requir inspections. Complete drawing on reverse side. <br /> Signs `-+ Title: - S Date: <br /> FOR DEPARTMENT USE ONLY <br /> _Application Accepted by Date / Area <br /> Pit or Grout Inspection byDate Fin 1 Inspection by CD Date� Z _� <br /> Additional Comments: <br /> Applicant - Return all copies.to: SAH OAQUIN COUNTY PUBLIC HEALTH SERVICES { �C) <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> FEE INFO AMOUN/(T�DDUUE AMOUNT REMITTED CK <br /> SH RECEIVED BY DATE f ERMl7 N0. <br /> . EH 2�if1EV,iie7i <br /> A- g�l. ✓ �t 'CI I't t��_ / ��� <br /> EH;fsa <br /> R• <br />