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APPLICATION FOR PERMIT <br /> ' <br /> SAN JOAQUIN- COUNTY PUBLIC HEALTH SERVICESt � <br /> ENVIRONIdENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 0}J�„p� <br /> PER][IT EXPIRES 1 YEAR ?RQX DATE. ISSUED 2R <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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public HealthServices./'� <br /> Job Address _ 1� I /] / j�v � ��r City d Lot Size/Acreage <br /> Owner's Name 9I'/a U�-S Address Cr Phone <br /> Contractor T P,5LU/ .J�Y� Address -�TA#' V S-go�-Sr y"/g 'S'��7 � <br /> Icense No. Phone <br /> TYPE OF WELL/PUMP: NEW'WELL`❑ : WELL REPLACEMENT n DESTRUCTION 0 out of Service Well 0 <br /> PUMP INSTALLATION-0 4 x SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK " SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION S 'r AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_l industrial 0 Open Bottom ❑ Manteca,{ Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy '` �,� Type of Casing Specifications <br /> MPublic f-I Other,.:, ,. p Delta Depth of Grout Seat Type of Grout <br /> 0 Irri0ation _..Approx.-Depth 0.Eastern _ t Surface Seal Intlalled by L <br /> Repair Work Done ❑ Type of Pump H.P. ` t Stare Work Done_ <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> r <br /> Depth Filler Material & Depth <br /> TYPE: OF SEPTIC WORK: NEW'INSTALLATION L7 REPAIR/ADDITION DESTRUCTION CI INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence�L Commercial— Other �\ f <br /> Number of living units: Number of bedrooms r <br /> Character of$oil to a depth of 3 feet: ►9-tti-___ - 'Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg n �'`�C-e^�t- Capacity b 'No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> i 1 <br /> LEACHING LINE 0 No. & Length of linesa '"_. ��� Total length/size <br /> FILTER BED n Distance to nearest: f,_ Well 1 Foundation Property tine <br /> f w, t <br /> 4 r . <br /> SEEPAGE PITS i I Depth r Size Number � <br /> SUMPS Ll Distance to naarest�� 'Welt / SC9 t Foundation 13 O 0'- Property Line _/./_10 <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 laws, and <br /> rules and regulations of the San Joaquin County , <br /> Home owner or licensed agent's signature certifies the following: "t 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 /> eartifies 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 /> tion laws of California." ., f <br /> The applicant must tail for all required inspections. Complete drawing on reverse side. <br /> Signed XTitle: Date: / Z'�_gy <br /> f FOR DEPARTMENT USE ONLY <br /> licetion Accepted by _..,.,...__ Date Area 2i <br /> Plt or Grou! Irnpection b !i�� Date t�~ �`� Final Inspection by�Y"`` J Date } �8 ew <br /> _ . _ <br /> Additional Comments: <br /> Applicant Return all copies to: SAN JOAQUIN-COUNTY PUBLIC HEALTH SERVICES <br /> „ - -ENVIRONMENTAL HEALTH-DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 98201 <br /> INPOFEE A1MOO11UNT DUE Aj,Mp1UNT REMiTTEO 00 <br /> CASH RECEIVED BY DATE PERMtT'N0. <br /> + JH 13-24 IREY.t/Ns1 t� rIO l~`T ^Z --cro (�31 <br /> EH 14•sa <br />