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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 /> HERMIT .EXPIRES 1 YEAR 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 compliance with San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> lab Address I 4EI C�Q KA9'7f City Lot Size/Acreage COAG, <br /> Ow Is Name t � Address t 1 MJ Phone <br /> ContractorEAM Address .�� �TC.�.�L._If1�� License No. Phoney <br /> TYPE OF WELL/PUMP: k NEW WELL ❑ ELL REPLACEMENT -- DESTRUCTION ❑ Out of Service well 0 <br /> PUMVINSTALLATION © SYSTEM REPA ❑ fir OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU WELL Z OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO ST UCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ MantecaAia, Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack 0 Tracying lSpecifications0 Public I'1 Other ❑ Deltaout Seal Type of Grout <br /> M Irrigation Approx, Depth 0 Easternl Installed by <br /> Repair Work Done L7 Type of Pump H.PState Work DoneWell Destruction ❑ Well Diameter epth <br /> Depth i iller Material i De h .� <br /> TYPE OF SEPTIC WORK; NEW INSTALL9TION REPAIR/ADDITION Lf DESTRUCTION CJ 1No septic system permitted it public sewer is <br /> V/ t QS available within 200 feel) <br /> Installation will serve: Re 'dente^ Commercial__ Other <br /> 1- <br /> Number of living units: 'Number of be , <br /> ii oms <br /> t <br /> f Character of wit to a depth of 3.,faet: � F Water table depth <br />` SEPTIC TANK. ❑ Type]/Mfg apacity_. � '� No. Compartments Z <br /> PXG. TREATMENT PLT. Q .s_ { E Method of Di sal <br /> Distance to nearest: Well `.#b• 'Foundatiori* Property Line 3 <br /> LEACHING LINE WIN0. 8 Length of lines .:.—ToTal°length/size <br /> FILTER BED ❑ Distai,ce to nearest: Well foundation - .Ar I Property Line <br /> r <br /> SEEPAGE PITS 11 Depth Site r r ,.. .�_�o r I —Number' <br /> SUMPS LI Distance to nearest: Well - Foundation_ Property Line <br /> DISPOSAL PONDS ❑ Yi <br /> I hereby certify that I have prepared this application and that the work will be done in accgrdan a with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County --' I <br /> Home owner or licensed agent's signature certifies the following: "I erti#y that in the perfoLr ai4e.o#the work for which this permit is issued, I shall not ., <br /> employ any person'in such manner is to become subject to workman's compensation laws-of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that i the performance of the work for which this permit is issued, I shill employ persons subject to workman's compensa- <br /> tion laws of California." I - <br /> The ap ant st requir io omplete drawing on reverse side. J 1 . <br /> Signed f. Title: Dater --I i�4Q � A I <br /> �.. �.. _FO D #7.USE ONLY."' ;::g3, <br /> Application Accepted by <br /> Date 1 rea, i <br /> Pit or Grout Inspection by Date Final Inspection by Date Q <br /> Additional Comments: ' t <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 SOX 2009, STOCKTON. CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT RE1441T1Ep CASH RECEIVED BY DATE PERMII'NO. <br /> I <br /> . EH 17.24IREV,,�eel ' <br /> Al 1 <br /> i <br />