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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-a4443,/.2-0 <br /> RES I PAT ISSUED <br /> Y <br /> (Complete in Triplicate) <br /> Application is hereby made to Sad Joaquin County for a permit to cons truct'and/or"install the work herein described:. This <br /> application In made in couplience with San Joaquin County Ordinance No.. 51+9 and 1862 and the Rules and Regulations <br /> 1 oT,rSan <br /> Joaquin County Public Health Services. <br /> ^� + / <br /> Job Address i Lan c;ty - Lot Size/Acreage <br /> Owner's Name 08 / ' N Address <br /> — ,.•. Phone' V <br /> Contractor_ 'TZctp-aSS4's4w Address 2 u <br /> License No. .300,r ' 'Phone S -d77 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> PUMP INSTALLATION;O _SYSTEM REPAIR a7r OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK - `d. .._ SEWER LINES DISPOSAL FLD.x " PROP. LINE ]Q_ <br /> FOUNDATION �^AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_] Industrial 0pen Bottom Iff Manteca Dia. of Well Excavation <br /> '"omastic/Private ❑ Gravel Pack Dia. of Well Casing Or' <br /> ❑ TrY Type of Casing Fee Specifications <br /> CJ rrivat Cl Other ❑ Delta depth of Grout Seal =/ <br /> CJ Irrigation �/ � s -D Type of Grout��_ <br /> 1/Q Approx. Depth ❑ Eastern Surface Seal installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter _ Sealing Material k Depth—- <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION CI 1No septic system permitted if public sewer is <br /> Installation will serve: Residence Cavailable within 20O feet,d <br /> — ommercial— Other <br /> Number of living units: Number of 6adrooms <br /> Character of *oil-IQ a depth of 3 feet: T <br /> SEPTIC TANKWater table depth <br /> /Mfg aci[y No. Compartments <br /> PKG, TREATMENT PLT. Cl <br /> ~F^-- ,Method of Disposal <br /> Distance to nearest: II Foundation Property Line <br /> 1 . <br /> A <br /> LEACHING LINE 0 No. & Length of ' s Total length/size f <br /> FILTER BED CI Distance nearest: Well Foundation PPr_operty Line <br /> SEEPAGE PITS Depth Size <br /> SUMPS �' � Number <br /> LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PO DS 0 { <br /> I hereby cenify 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: ".I cenify 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 subjecHo woriiman'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." <br /> The applicant mu t tail far I! re red ins r <br /> q inspections. Complete drawing on reverse e', <br /> t <br /> Signed Title: 9� <br /> t <br /> Date: <br /> 1 F R D ARTMENT USE ONLY <br /> Application Accepted by r <br /> Date .2 Area <br /> n _ <br /> Pit or Grout Inspection by �' r Date Z Final Inspectioby <br /> Data <br /> Additions! Comments: <br /> Applicant_- Return all eo tea to: t Q — <br /> _p SAN JOA UIN COUNTY PUBLIC SERVICES <br /> Y945ZNOSAN JOAQUIN,TP OIBOSION ERSTOCKTONICCA 85201 <br /> INFO ES <br /> AMOUNT DUE AMOUNT AEMtTTED CX <br /> CASH RECHVED sy DATE PERMIT NO. <br /> . E ' 1PEY.iiay) <br /> EHNV9P <br /> r <br />