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APPLICATION FOR PERMIT <br /> -•.� SAN-JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> -1 Coe ENVIRONMENTAL HEALTH DIVISION <br /> I 445 N SAN JOAQ UIN PHONE (209)468-3420 <br /> - � P O BOX 2009, STOCgTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE LSSJUED <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 }Toa win Co ty Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ]" (� ` Z_ 5-) oC-4ro ti/ <br /> Job Address 2�TF ��� �"� City Lot Size/Acreage <br /> : Owner_'s-Name L Address Phone �+ <br /> Contractor L ddress lj F License No. Pho <br /> TYPE OFI WELL/PUMP: , NEW WELL WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well 0 <br /> Monitoring Well <br /> PUMP'INSTFi1:l.ATI01J- SYSTEM REPAIR C7 OTHER ❑ Q � ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> f 4 _ FOUNDATIONS AGRICULTURE WELL � OTHER WELL �- PITS/SUMPS <br /> E INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation ' Dia. of Well Casing�/ <br /> l lrpomeatic/Private Gravel Pack_ '. ❑ Tracy Type of Casing - C. ,15 �1 1 � <br /> Specifications�Z ��-� <br /> _ <br /> i <br /> fl Public (-1 Older f7 Delta Depth of Grout Seal r!0'D Y' IIS Type of Grout. 1-- <br /> r Ligation _Approx. Deppt�t''h99��I��.I Eastern tSu�riace Seal Installed by <br /> Repair Work Done 1� Type of Pump H,P. f�7 State Work Done _ <br /> Well Destruction 0 Well Diameter ��- Sealing Material i Depth "' <br /> { Depth Filler Material i Depth <br /> T OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I {No septic system permittedif public sower is <br /> available within 200 feet.) <br /> Installation.suit Residence— Commercial_ Other t <br /> Number of living units: mbar of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t t Distance to nearest: Well' Foun f Property Line <br /> E LEACHING LINE ❑ No. a Length of lines Total len ize <br /> FILTER,BED 0 Distance to nearest: Well Foundation Property LI <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this a6f5lication.and'that the work will be done in accordance with San Joaquin county ordinances, state laws, and.- <br /> l 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 subcontracting signature <br /> certifi"the following: "I certify that in performance of the work for which this permit is issued, I shall employ persons subject to workman'*compensa- <br /> tion laws of C <br /> 'A <br /> The applies c E or alt Complete drawing on reverse side. <br /> Signed 1 Title: �u Date: Z <br /> IF R`DEPARTMENT USE ONLY �1 <br /> Application Accepted by Date ^d` Area <br /> r Pit or IGrout Inspection by Data - Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 X San Joaquin, P O Box 2009, Stkn, OA 95201 <br /> Nj -AMOUNT DUE AMOUNT REMITTED" CK H RECEIVED BY DAT PERMIT'NO. � <br /> TR 11=24 InEv,i i#15) <br /> EH j11.28 <br /> !1 <br /> I - <br />