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t APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> SIT EXLTRES i 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 Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County <br /> �Public <br /> /Health Services. <br /> Job Address !► �±"L was C'p~�� City_5/LOCg�^/ Lot Site/Acreage ^ 701t1C�Cfs <br /> Owner's Name f+'� �e+ser A40LOhrG f 0111 WO"Address S'4#pr►e ___ _-__ Phone0 `Y "Sam <br /> '^1 +� GS-87/L. <br /> Contractor 1t•tJh. �it,rl„C.royL Address!e8zSE�TG.C_� License No. ��2�68 Phone <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER f$( Z7 Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES, DISPOSAL FLD. PROP. LINE <br /> I <br /> FOUNDATION: "` AGRICULTURE V LIL `;a �, - OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial D 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 i <br /> M Public Cl Other 0 Delta Depth of Grout Seal Type of Grout i <br /> 0 Irrigation Approx. Depth 0 Eastern Surface Seal Installed by ' <br /> Repair Work Done 0 Type of Pump H.P. §IaTe <br /> 6 N <br /> , Work one <br /> Destrction 4xDiameter SealingMaterial 4 Depth _ <br /> k <br /> e"wt4y,— <br /> Depth C �2p 1C7' Filler Material S Depth , ZV <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION G (No septic system permitted it 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 10 a depth of 3 feet: { <br /> SEPTIC TANK 0 Type/Mfg Capacity 0�r, P-S rrel-111e <br /> PKG. TREATMENT PLT.❑ 11_ or ispQ <br /> Distance to nearest: Well Foundation PropertAUf0 1 <br /> 5�4 V <br /> LEACHING LINE ❑ No. & Length of lines Total <br /> FILTER BED n Distance to nearest: Well Foundations <br /> i <br /> s <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL_ PONDS 0 ti <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 i <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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> 1 <br /> The appkic m t call for all required inspections. Complete drawing on reverse side. / <br /> Signed �_ '� - Title: _/2.16►.r< <br /> o <br /> Lrc��eG•tr p e; <br /> V -- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _014Date & 3/" 2 <br /> Pit or Grout Inspection by Date Final Inspection by 011111ipate <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 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH nt rriv'ED BY DATE PERMIT'NO, <br /> • <br /> EH 13-24 I NEV.1/n 51 O4 � <br />