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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FR OId DATE ISSUED <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 Joaquin County Ordinance No. 549 and 1862 and the Aisles and Regulations of San <br /> Joaquin County Public Health ices. <br /> Job Address .) City Lon Lot Size/Acreage <br /> Owner's Name Mal Address 1,Dqn VAI YF Phan <br /> Contractor <br /> Address License No.Z's cel Phone <br /> TYPE OF WELL/PUMP: N W WELL O WELL REPLACEMENT 171 DESTRUCTION Cl Out of Service well Cl <br /> PUMP INSTALLATION © SYSTEM REPAIR OTHER D Monitoring well C] <br /> DISTANCE TO EAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED SE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> LI industrial D Open Bottom 0 Manteca Dia. of Well Excavation Dia.1.of Well Casing <br /> �h <br /> Domestic/Private. Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> f'1 Public i'1 Other n Delta Depth of Grout Seal �^�Typ6'd!"GriSut <br /> I i Irrigation I Approx. Depth I I Eastern Surf a Seal Installed by <br /> Repair Work Doe'te 0 Type of Pump H.P. State Work Done — <br /> Well Destruction �O Well Diameter <br /> If Sealing Material i Depth <br /> Depth I() t biller Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation will! serve; Residencem <br /> _ Commercial— Other <br /> ther <br /> Number of lmv q units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: A + Water table depth <br /> SEPTIC TANK. O Type/Mfg I Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property <br /> LEACHING LINE CI No. S Length of lines Total length/si: <br /> FILTER BED O Distance to nearest: Well Foundation Properirine 4 <br /> 0 p 1 tAprJJL� <br /> i I <br /> SEEPAGE PITS I I Depth Size Number AN JOAQUIN COUNTY <br /> rUbLIU L _ 1[,ES <br /> SUMPS Li Distance to rtesrest: Well ' Foundation________ � rr4lat H€ tTN IVISIOfV <br /> DISPOSAL PON S ❑ <br /> I hereby unity that I have prepared this app Icatw�{-"n andiha(the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulo6ons of tate San Joaquin County <br /> Home owner or I;icensad 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 par - such manner as to become subject to workman's compensation laws of California.';Contractor's hiring or sub-contracting signature <br /> certifies the f wi : "I cefi ty that in the perforniince of-the work'foFwl+ich this pe►mri a risu shifiimpl6 I eo 0 a subject to workman's compensa- <br /> tion laws le." <br /> The appy nt at call for allr irad inspac' ns. Complete drawing on r or Ida. <br /> Signed Title: 24^ Date: <br /> FOR EN USE ONLY I I Application Accepted byQCA�1� Date •/ <br /> dArea 07--12, <br /> Pit or Grout Inspection by I Date Final Inspection b Dat <br /> Additional Comm ants: <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 <br /> )NFO AMOUNT DUET AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. <br /> . EH 13.21 IR1N.1i0,41 <br /> EH 11•26 <br />