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s APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION t <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y R <br /> i <br /> (Complete in Triplicate) <br /> Application is hereby made,to SanlJoaquin County for a permit to construct and/or install the work herein described. This l <br /> application is made 1n cotrtpllancejwith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health)Services. r,r ` — ; <br /> ob Address �O tlt ri "'r1 V CL(Sd City � �� Lot Size/Acreage � <br /> J � T/� <br /> KOwner's Name�r N PsT 6 �Y 66 Address r Q I mos l r M C z Phone 3� <br /> Ccntratio �"V �'Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 <br /> PUMP INSTALLATION 5� SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION.— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> LU Domestic/Private - Ll Gravel Pack ❑ Tracy Type of Casing" Specifications <br /> M Public to Other 0 Delta _Depth of Grout Seal Type of Grout <br /> M Irrigation Approx, Depth ❑-Easterni /Surface Seal installed by <br /> Repair Work Done U Type of Pump; ' H.P. F�a� _ State Work Done _ <br /> Well Destruction O Well Diameter l Sealing Material i Depth <br /> De Filler Material i Depth ? <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L} REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is <br /> I available within 200 lest.) <br /> Installation will serve: Residence j Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of$oil to a depth of 3 feat: Y' Water table depth <br /> SEPTIC TANK- ❑ Type/Mfg f Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 s Method of Disposal <br /> Distance to nearest: Well Foundation Property Line t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to n<k earest: Well Foundation Property Line k <br /> SEEPAGE PITS I I Depth I I Size Number <br /> SUMPS Ll 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 cenifies 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa" <br /> tlon laws of California." <br /> The spplic 2MUScallf r 71r,. � dins ons. Complete drawing on reverse side. <br /> 3�5ignsd }L . - - , Title: Date: �;,=.;_,, <br /> FDEPARTMENT USE ONLY. <br /> Application Accepted by Date A'� l� Aria <br /> Pit or Grout Inspection by Date Final Inspection by pate / /S <br /> Additional Comments: <br /> rf .. <br /> Applicant - Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O nOX 2009, STOCKTON, CA 95201 <br /> FSE t� <br /> INFO AMOUNT DUE AMOUNT REMtTTEO CASH E4Y DATE PERMl7'NO. <br /> EH p <br /> EH�� tREV.ii�Si ��^ -OCA ��3Z `d_.3 "'a1�7 � e� <br />