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` i t <br /> 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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED <br /> # (Complete in Triplicate) <br /> r <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 castpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. y--} <br /> Job Address 3 So �`r AV City i r� Lot Size/Acreage 2cR <br /> Owner's Name +3 P ­0!� J Address Phone <br /> Contractor Mafia Y-� Address to-0,136X 3 a 992/4_icense No. Phone r+�a 14 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑# SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DlSP05AL FLD. PROP. LINE <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial + ❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia. of Wali Casing <br /> 17.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'I Public 1-1 Other 'f fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ . Type of Pump ' H.P. State Work Done <br /> Well Destruction ❑ Well Diameter `j Sealing Haterisa .i Depth <br /> Depth I Tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITtON DESTRUCTION 1>49No septic system permitted if public sewer is <br /> „ - - ] - available within 200 feet.) <br /> Installation will serve: Residence_ a Commercial: Other <br /> Number of living units: Number of bedrooms <br /> Character of soU to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/M19 t Capacity /Zud No. Compartments 2-- <br /> PKG. <br /> PKG. TREATMENT PLT:C7" +� """" �Method of Disposal r <br /> Distance to nearest: Well S"d Foundation T Property Line <br /> ,I <br /> LEACHING LINE Cl No. 6 Length of lines ��'S 3� j Total length/size <br /> FILTER BED Distance to nearest: Well --0 'Foundation ' �V f Property line 12 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS U.W Distance to"nearest: aWell _Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 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 /> Horne owner or licensed agent's signature certifies the following: 'V 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 work man's'compensation laws of California..' Contractor's hiring'or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is'issued, f shalt employ parsons subject to workman's eornpensa <br /> tion laws of California." <br /> The applicant must tali for all required inspections. Complete drawing on reverse side._ <br /> signed - Title: ? ..��. Date: Y ! 8 S g <br /> FOR DEPARTMENT USE ONLY Q �( 7 <br /> Application Accepted by Date ` _ Area ¢/� <br /> Pk or Grout Inspection by Date y Final Inspection by Date <br /> Additional Comments: <br /> �< L1 t 4 &6irl 6C` - -42 <br /> s <br /> Applicant - Return all copiee[to' "San Joaquin County Public Health Services <br /> copies,[to' <br /> Health Permit/Services <br /> 445 N San Joaquin, PXO'Box-2009,—Stkm,-CA-95201 <br /> FEE AMOUNT DUE � AMOUNT REMITTED CASH RECEIVED BY GATE PERMWNO. <br /> INFO <br /> iH1 <br /> LV <br /> . EH 13.24 IREV.rix5J <br /> E+1 11.20 i/ <br />