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APPLICATION FOR PERMIT <br /> ..' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, ,STOCSTON, CA 95201 <br /> ! <br /> PERMIT EXPIRES 1 YEAR FROM DATE I S <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 compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. r <br /> Z j � Lot Size/Acreage <br /> Job Address 62 Cary <br /> -elf' , <br /> Owner's Name a � r = AddressPhone <br /> ' <br /> Contractor �,t .� Address r :fix - License No. ' +� " Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WEL•i:�REPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL 'PITS/SUMPS O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1 1'a Domestic/Private ❑ Gravel Pack [ITracy Type of CasingMID s <br /> I'] Public 1-1 Other l 171 Delta D t ut <br /> I I Irrigation Approx. Depth I I Eastern SUBfacd'Snii I!3 kJ <br /> Repair Work Done ❑ Type of Pump H.P. 5,taLq,lNgclB � ...ikr, �+ <br /> Wall Destruction ❑ Well Diameter Sealing Mater lIc4VC G }}3J l�F9rC <br /> Depth biller osteo {,fnm[11P.tP.t"� Of insoeC e <br /> f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I Y4l PM-1201 <br /> N ted if public saww is <br /> '! 200 feet.) <br /> Installation will serve: Residence Commercial Z Other e' r/T <br /> Number of living units Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 90, TypelMfg Capacity� No. Compartments <br /> PKG. TREATMENT PLT.❑ D 5 / Method of Disposes <br /> l Distance to nearest: Well Foundation � - Property Line <br /> LEACHING LINE No. 8 Length of lines �� Total 4Ingth/size c)Q <br /> y <br /> FILTER BED Cl Distance to nearest: NVell 170 Foundation - -- Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> I 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 /> 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 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 compenss- <br /> tion laws of California." <br /> The applicantrp call for all requirso onspgc ns. Complete drawing on reverse side. <br /> TO <br /> I i Sigma Title: ` �f - - - Date: l�� .». . <br /> lK RR DEPARTMENT USE ONLY c, q <br /> Application Accepted byLQSA.-'& - +�+—�A� WV, � -- Data i r Z � - Area Z l <br /> 4 Pit or Grout Inspection by Data Final Inspection by Data <br /> Additional Comments: f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DTE PERMIT'N0. <br /> INFOe Q ++ <br /> Ex„1i2�IREV,rins! �' {Y <br /> EM 4.26 yl Ag <br />