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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)468-3420 It <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT "IRES 1 YEAR FROM„UTE 1ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby.mnde to San Joaquin County for a permit to construct and/or install the Work herein described. This <br /> application is made in coupliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Ban <br /> KJ <br /> oaquin County Public Health Services. <br /> Job:AddressCCity- &=2km, Lot Size/Acreage <br /> 07 <br /> LContractor <br /> Address Phone <br /> C&-a ta! Address License No. Phone <br /> TYPE OF WELOPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER-❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ! 0 I AGRICULTURE WELL 0 }piP <br /> INTEND USE F PROBLEM AREA CONSTRUCTION SPE FICATIONS <br /> jC7 Industrial Bon ❑ Manteca Dia. of Well Excavation �t of VM Casing <br /> # .C] Domestic/Private CI�Gr Pack ❑ Tracy Type of Casing_ 5peeific t' ns <br /> I'] Public ther n Delta Depth of Grout Seal 3 0 <br /> r I I Irrigation --'�Xp ox. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type If ump H,P. State Work Done_ <br /> k Well Destruction ❑ Wel iameter Sealing Material JI Depth <br /> Dept` Filler Material A Depth <br /> h 19 <br /> YPE OF SEPTIC WORK: NEW INSTALLATION^ REPAIR/ADDITION I I DESTRUCTION I I (No sep " J7� <br /> ttr�d,�I public sewer is <br /> available wI v <br /> Installation will serve: Residence '✓ Commercial__ e a <br /> Number of living units: Number of bedroomsF <br /> Character of wd to a depth of 3 feet. _ Wate <br /> SEPTIC TANK. Type/Mfg Capacity �'i?DC7 No.PKG. TREAT NT PLT. Meth <br /> i^ Distance to nearest: Well 1049 FTdafiewaRmt-4 <br /> LEACHING L E No. b Length of lines TotilIg�ttI /size <br /> FILTER BED Distance to nearest: Well ''°/ s le_N <br /> I - <br /> SEEPAGE PIS ' I I Depth Size er <br /> Numb <br /> SUMPS Distance to nearest: Weil Foundation 704 Property Lina li(JD J <br /> DISPOSAL PONDS ❑ <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 Wgnaturs certifies the following: "I certify that in the performance of the work for which this permit is issued, I shad not <br /> employ any person in such manner as to become subject to workman's compensation taws of CsWornia." 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 compensa- <br /> tion laws of California." <br /> he applicant must call for all required inspections. Complete drawing on reverse side. <br /> igned X - - Title: -�.,LJ�,..1"`u ' _._ Date: <br /> ,4 �DEPARTMENT USE ONLY <br /> Application Accepted by �'�^� - _ Date 11) <br />`J Pit or Grout Inspection by Dais Final Inspection by Data�� <br /> W <br /> Additional Comments: <br /> :Applicant - Return all copies to: San Joaquin County Public Health Services r <br /> Environmental Health Permit/Services F <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 s <br />_ iIFEE. INFO AMOUNT DUE AMOUNT REMITTED C H REC VED 8Y DATE PERMIT'NO. <br /> r <br /> Ell 113-24 0�- <br /> " <br /> EM N•m <br /> I <br />