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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O SOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT BUIRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mde.to San Joaquin county for a permit to construct and/or install the vork herein described. This <br /> application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. { <br /> Job Address u� .7 � 1,1)n r AEtJ_ A e e City Lot Size/Acreage <br /> Owner's Name MQ P. K . 6, ,, x Address /-4-7 L :Sil'ax r° l/.n e LI U r? Phone 2 11- <br /> Contractor h Address -r �_ License No.�g613 S3 Phone a 7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT •n• DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLA.TIONA SYSTEM REPAIR M OTHER ❑ Monitoring Well [1 <br /> DISTANCE TO NEAREST: SEPTIC TANK hQQSEWER LINES DISPOSAL FLO. PROP. LINE LfrZ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ! PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C# industrial EI Open Bottom ❑ Manteca Dia. of Well Excavation ­-Dia.-of Well Cas'ng <br /> X Domestic I Private 'Gravel Pack ❑ Tracy Type of Casing o• e+ — Specifications- <br /> A Public Cl Other Q Delta Depth of Grout Sea! c20Q ',- Tye of Grouts r-en.c <br /> r �� _ <br /> Ca Irrigation 3�Approx. Depth Eastern Surface Seal Installed by t cr'c,�! P:r �� n 4 <br /> Repair Work Done U Type of Pump _ N.P. State Work Done <br /> Well Destruction O Well Diameter <br /> 3ealirlg Material i Depth J <br /> Depth �111er Material i Depth, <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION 0 REPAIR/ADOITION 0 DESTRUCTION 1=I lNo septic system permitted if public seweJi3 <br /> available within 200 feet.) <br /> Installation will serve: Residence_.._. Commercial.-.... Other <br /> Number of living units: Number of bedrooms + <br /> Character of $oil to a depth of 3 feet: Water table depth y <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLt. ❑_' f{ Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE Cl No. & Length of fines '--t- Total length/sire <br /> FILTER BED n Distance to nearest} Well,` Foundation Property Line <br /> � I <br /> SEEPAGE PITS 11 Depth 'P Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <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 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 uubject to workmen'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 shaii employ persona subject to workman's compansa- <br /> tion laws of California." 1 <br /> The applicant must call for all required inspections, Complete drawing on reverse`side, <br /> Signe+ Ida it ,'tc.Q2 Title ' � l_� z' Date: <br /> 1 <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by rl A. Date___3,-�_ Area { <br /> Pit or Grout Inspection by 7 V Date LJ/ Final Inspection byn" Dated 5.( <br /> Additional Comments: _ <br /> Applicant - Return all copies tot SAN JOAQUIN COUNTY PUBLIC• HEALTH SERVICES <br /> ENVIRONMENTAL, HEALTH.DI.V_ISI.ON PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> -FEE —AMOUNT DUE AMOUNT REMITTEO CK fiECEIVEO BY, PATE PERMIT'NO, <br /> INFO CASH Q E <br /> EH 13.24 ift Ev.1/N 51I -1 11 <br /> �N 44•jli -e 6-0 -3 <br />