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1 t <br /> 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 /> YEAR MOM- PATE ISSUED <br /> I (Complete in Triplicate) <br /> -Application is hereby made to Sam Joaquin County for a'permit to construct and/or install the work herein described. This <br /> application is made in co�liance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address �.-���1 �►�• 40W£4 S Ilk rid_••— City 4 Lot Size/Acreage <br /> / f <br /> ` Owner's Namet�l/�S Address �l>c.+G�'�, -� - Phone <br /> �--.mow.,. ., .. n . . ... -. �- �.. ....,- . - w.-.,,....-.--.._ _,..—...•........:,,.... <br /> Contractor '5 -/ ?r P .Address'„`. 'ex 2/t' . G �a _ License No r"a • Phonef' C ?dam <br /> TYPE OF WELL/PUMP. .� NEVV WELL 0 WELUREPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 17 SYSTEM REPAIR ❑ OTHER © Monitoring well U <br /> DISTANCE TO NEAREST:;SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE _t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LJ Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing. Specifications <br /> ❑ Public 1:1 Other Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation .Approx. Depth L1 Eastern Surface-S oil Installed by <br /> Repair Work Done L] Type of Pump H.P. ? State Work Done <br /> Well Dastruction ❑ Wali Diameter Sealing Meterlal &'Depth <br /> ! 4 Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: KNEW INSTALLATION REPAIRIADDITION M DESTRUCTION 3K INo septic system permitted if public sewer is W <br /> f available within 200 loot.) <br /> Installation will serve: Residence____. Commercial,_,�_ Other <br /> t Number of living unite: Number of bedrooms r <br /> ♦Y � <br /> Character of soil to a depth of 3 feet, f s ,r Water table depth <br /> SEPTIC TANK: ,� Type/Mfg .4212 -92 e.&L CQA-C&C 116uCapacity— No. Compartments - <br /> PKG. TREATMENT PLT. 0 ° a I i Method of Disposal <br /> x Distance to nearest: it Well Foundation <br /> Property Lina <br /> LEACHING LINE No. & Length of linesf Total length/size <br /> FILTER BED C.] Distanc"to nearest r Well /svC Foundation for Property Line <br /> it 4 _ <br /> r <br /> SEEPAGE PITS Number12— <br /> .f�i' Depth r -Size y t <br /> SUMPS LIDistance to aarasrr� Well Foundation.. ed Property Line /a ` <br /> DISPOSAL PONDS ❑ : '" <br /> I hereby comity 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 J6aquin 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 /> f 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 /> comilies the following: "I certify that in ft;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." f <br /> The applicant m t call for all r quire d inspections. Complete drawing on reverse, side, <br /> Sign sd Title: pate; <br /> FOR DEPARTMENT USEONLY <br /> C 1 <br /> Application Accepted by �— _...__.._ Date `U ` Area r <br /> it Grout Inspection binm Date ✓Z Final Inspection bDate/C) <br /> ' Additional Comments: <br /> r Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOA 2009, STOCKTON, CA 95201 <br /> lNFO AMOUNT DUE AMOUNT REMITTED CASH K If REC1 .EIVED BY DATE PERMIT'NO- '- <br /> 1 11f 1190Y <br /> Eli 74,21 <br />