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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 Y FR M D E <br /> (Complete in Triplicate) _ <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cosopliaace with San Joaquin County Ordinance No. 549 and 1662 and the Aides and Regulations of San <br /> Joaquin County Public Health Servioye. <br /> Job Address <br /> D 1 <br /> City <br /> / Lot Size/Acreage <br /> J ) Phone r <br /> Owner's Name�v I Address _ <br /> �J-0 <br /> Contractor Address c�ese No. qc3 — <br /> dyPhore <br /> DESTRUCTION ❑ Out of Service Well 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �—.�- PITS/SUMPS <br /> fOUNDATION, _)AGRICULTURE WELL. OTHER WELL ' <br /> INTENDED USE TYPE SOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Diaof Well Casing <br /> II C7 IndustrialD Open Bottom A ."❑.Manteca Dia. of Well Excavation Specifications <br /> t 1.1 Domestic/Private ❑ Gravel Pack ❑;Tracy Type of Casing_ Type of Grout ' <br /> I 11 Public Other' --_n 7Delta"—.mss Depth of Grout Seat <br /> Surface Seto lnatelled by <br /> I I Irrigation —.Approx. Depthlr l I Eastern f <br /> Repair Work Done U Type of Pump <br /> \ Stats Work Done <br /> H.P. _ <br /> Sealing.tfaterlal fi Depth <br /> Well Destruction ❑ Well Diameter f r <br /> Depth 1 ,f Filler MaterialA,Depth <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION-1 1 REPAIRlADDITION DESTRUFLION'I I (Nailableo septic shin 200 syslem rent€d if public sower is O <br /> Installation�wtll serve: Residence— Commercial— Other <br /> Number of living units. Number of bedrooms Water table depth <br /> E�haracter of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ •Type/Mfg Capacity-- No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well' Foundation Property Line <br /> ! LEACHING LINE El 'No. f1, Length of lines Total IengthJsixe 1 <br /> FILTER BED D Distance to dearest: Well _Foundaiion Property Line <br /> � # SEEPAGE PITS it Depth Site - Nu r <br /> SUMPS LI Distance-to x rest: We11 d Foundan Property� � - <br /> 'y � <br /> F <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;-atate"laws, and <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,ot the work for which this permit is issued, I shall not <br /> /employ any person in such manner as to become subject tp workmen's compensation taws of California." Contractor's hiring or sub contracting signature <br /> 1:artifies the following: ''t caRlfy that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion°taws of California... <br /> .�` The appy '�+nast-fall for a�r� "ad i ct�pa ions�mplete drawing on reverse side. ` - <br /> �_�f/�iY�_. ., Date: <br /> Signed )(�.T — Title: <br /> FOR DEPARTMENT USE ONLY n <br /> Data Area s-- <br /> A ication Accepted <br /> -bby ! v <br /> }6 'L� ���-40-F al inspection by Dats _- <br /> or rout inspection by - Date— <br /> l Additional Comments: <br /> - Applicant - Return all"copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEEK RECEIVED BY DA E PERMIT'NO, <br /> IN ODAMOUNT DUE < AMOUNT REMITTE4 <br /> EH 13 2�IAEV. / 6M <br /> �/ L <br /> p EH 14-2E ' FJ <br />