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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 /> YEAR <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. 544 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address ,2�9 u4V/It�rnAl -- City s77<,L/ _ Lot Size/Acreage /gv,<w47 <br /> Owner's Name VA I- :Z-1 Al A SSOCI.4 7zx Address `f'3 Al S"6,e f 4 N=M-bll - Phone <br /> Contractor /-o s'a g=-• Address '7�✓_A1� 1 B .e7" . License tlo �3:�17r__-Phone 39 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT (71 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION CI SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PETS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial 0 Open Bottom 0 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> 0 Public I11 Other 0 Delta Depth of Grout Seal Type of Grout � 3 <br /> 0 Irrigation Approx. Depth l] Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION DESTRUCTION iMl fNo septic system permitted if public sewer is <br /> t.) <br /> Instillation will serve: Residence Commavailabl ithiercial_ Other � f�\ <br /> Number of living units: _J` Number of bedroomsy <br /> Character of soil to a depth of 3 feet. e•4.4,Y __ .Water table depth <br /> SEPTIC TANK 0 Type/Mfg X 1 S7-,'A1G Capacity No. Compartments r <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE J No. & Length of lines 1 - 40, Toral length/sire � <br /> FILTER BED n Distance to nearest: Well Foundation _ Ze Property Line 4K ~` <br /> SEEPAGE PITS I Depth 2::A: —Size _a Number ' <br /> SUMPS Ll Distance to nearest: WellN��4 Foundation —(� _ Property Line s <br /> DISPOSAL PONDS O � <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 Sen 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 following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant must c II for all required inspection .� omplete drawing onreverseside. <br /> Signed Title: - - Date: '2_Z Z —9 <br /> FOR DEPARTMENT USE ONLY C <br /> Application Accepted by Date A'� ` Area <br /> Pit or Grout Inspection by Date Final Inspection by ­-Date <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 O BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE �yPjERMIT'NO. <br /> . EH53-24IREV.I/"V J/ A/I� ��) �'� ZS �I `L _0 <br /> EH i{•26 <br /> y <br />