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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Z <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> 2EMIT. EXPIRES „I, YEAR rROM DALE ISSUE <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 j <br /> Joaquin County Public Health Services. <br /> Job Address T - City t Lot Size/Acreage - <br /> t[[ k <br /> Owner's Name �- �- ,,!?, tee e-k� Address e- ( ?^ Phone _s <br /> ,r"•s A f <br /> Contractor ih AddressPD- fi License Noc2lq_3�_ Phone ' <br /> _ <br /> TYPE OF WELL/PUMP. NEW <br /> _T rpt W_ELL�Q _ WELL REPLACEMENT C7 -DESTRUCTION ❑ Out of Service 11e11 C1 <br /> PUMP INSTALLATION' Y SYSTEM REPAIR D u OTHER (3 Monitoring Well -C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK 1120 SEWER LINES DISPOSAL FLD, PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_l IndustrialOpen Bottom ❑ Manteca Dia, of Well Excavation_fcDia. of Well Casing 'r <br /> Domestic/Private ❑ Mravel-Pack1 0 Tracy T e "7 P II <br /> YP �of Casing - Specifications <br /> M Priblic fa Other i p Delta Depth of Grout Seal `� r. Typ f Grouocr - <br /> G fr6oation C70D Approx. Depth ❑ Eastern Surface Seal Installed by e <br /> Repair Work Done U Type of Pump ,�� H.P. -_! . - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> ­Filler°Filler"Material & Depth- <br /> TYPE <br /> epth TYPE OF .SEPTIC WORK; NEW INSTALLATION❑ REPAIRJADDITION M DESTRUCTION G lNo septic system permitted if public sewer is <br /> available within 200 feet.) f <br /> Installation will serve: Residence„ +Commercial— Other <br /> Number of living units: Number of bedrooms , <br /> Character of axil to a depth of 3 feet: ^--- Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f <br /> Capacity-.41% No Cortipartments <br /> PKG."TREATMENT PLT.❑ i h 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 n Distance toynearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth I Sire plumber <br /> SUMPS LI Distance to nearest: Well foundatidn,.�'f 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 laws, and <br /> rules-and regulations of the San Joaquin County <br /> Home owner or,gcenssd 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 Bub-contracting signature a <br /> certifies the following; "I certify that in the performance of the work for which this permit is issued, I shali employ persons subject to workman's compensa- <br /> tlon laws of California.- r <br /> The applicant ust call for all required inspactions,_Complete drawing on reverse side; <br /> Sign ci4 Title: � .i' /? Date: <br /> FOR DEPARTMENT USE ONLY k, F <br /> Applicati ccepted by + 5 Date _ ,a I_ !� Area — <br /> P Grout spection b \ Data 1- �C' y Final Inspection b � � � „_._ Date v <br /> Additional Comments; <br /> COh&f U -1l0-'90' <br /> Applicant - Return all copies, to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> _-445-N-BAN JOAQUIN-,-P­O-BOX-2009, -STOCKTON, CA-85201-- <br /> FEE - q <br /> INFO AMOUNT pVE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO, <br /> .013-24(R¢v.i)h5, <br />