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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) 468-3447 <br /> PERMIT EXPIRES 1 XEA,R PROM DATE ,ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in cotgpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,h f` <br /> Job Address '��D .IV O aty_0 fn P=J City �OC�!_ Lot Size/Acreage /0 Q[ <br /> 4 �r n <br /> Owner's Name t1 � ��� .,,. f'�Addres/s� c�� 1 i�3 Yi n P Phone �3 706 <br /> Contractor ` h Address lr�'• t+"'i,L1Cr�1-��c� r��� License No. hpne <br /> TYPE OF WELUPUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK hb.hP SEWER LINES DISPOSAL FLO. PROP. LINE `±0 � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f�bC <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public Cl Other 0 Delta Depth of Grout Seal Type of Grout <br /> Cl Irrioation —Approx. Depth 11 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. Stare Work Done_ <br /> Well Destruction Wolf Diameter p Sealing Material k Depth /� <br /> Depth t Piller Material i Depth�y� J'S �P,,..e W nn 1 l� 6,11 U� , e r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION 0 INo septic system permitted if public sewer is �✓ <br /> available within 206 feet.) <br /> Installation will serve: Residence ^ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of&oil to a depth of 3 feel: Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ 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 171 Distance to nearest: Well Foundation Property Line <br /> E PITS 11 Depth Size Number <br /> S LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS p <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with Sart 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 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 of sub-contracting signature <br /> certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cornpensa- <br /> tion laws of California." <br /> The applicant must call for allZAAA1 <br /> red inspeAtions, Complete drawing <br /> �o^n�reverse side, <br /> Signe+�C„�� ,30 QAC(, Title: Date: 1` <br /> °r RTM_ENT USE ONLY <br /> Application Accepted by Date 7�1....��..©_ Area <br /> Pit or Grout Inspection by Date Final Inspection DateG. !/ <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201FEE <br /> INFO AMOUNT DUE AMOUNT REMMTED CA5H RECEIVED BY DATE PERMIT'NO. <br /> . EH 12 IREV,,/n <br /> E 51 <br /> hf-14,204,�.10 <br />