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t APPLICATION FOR PERMIT <br /> `i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONTAL\ HEALTH DIVISION <br /> t 445 N SAN JOAQUIN,' PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM 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. d 1862 and the Rules and Regulations of Sari <br /> Joaquin County Public LHealth Sery <br /> Job Address 0 ' � �Q City t Size/�Acreeage <br /> Owner's Nam, G/'7TllU WGFl�liltu3lRtdress 3757 r p �vaPhOne 14AW- 1 4) <br /> Contracl9:� 4Address s,�. �fr� "T License NAM Phone 6v f <br /> TYPE 2F WELL/PUMP:__. NEW WELL'❑ _ WELL REPLACEMENT n,._�., DESTRUCTION t of Service well C1 <br /> PUMP INSTALLATION p SYSTEM REPAIR ❑ OTHER ❑ 'Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE r_ <br /> ' -t_- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED-USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O <br /> ❑ Industrial ,_ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (, <br /> F1 Domestic/private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications V 1 <br /> (1 Public Ci Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H,P. 'i - State Wor D _ <br /> Well Deitruttion. VWNI Diameter ! sling`liaterial A Depth �} <br /> Depth )ler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i.IDESTRUCTION I I.INo septic system permitted it public sewer is <br /> L= avaitable within 200 feet.) <br /> In t Elation will some: Reside a Commercial Other <br /> Number of Irvin-units: mber of bedrooms <br /> Character of$ou to a depth of 3 fee i Water table depth Q <br /> SEPTIC TANK ❑ Type/Mfg Capacity rt <br /> No. Compaments <br /> PKG.-TREATMENT PLT.( ) Method of Disposal <br /> Distance to nearest: well/, <br /> ell Foundation Property Line <br /> 1 <br /> LEACHING LINE_,., L3 No. 3 Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Weil Foundation Property Line <br /> SEEPAdE PITS 11 Depth Size- ' Number <br /> SUMPS# A U Distanceto rest: Well undation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby comity-that I have prepared thi application and that the work will be don in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or ' n nt's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any rsbi in such nner as to become sub' to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the ollowiny: "I cert that int orma e !the work for which this permit is issued,I shalt employ persons subject to workman's compensa- <br /> tion laws Califor r-..-.. <br /> The appy ant mu c all'r it pl to drawing on a ode. 4 <br /> Signed Tine: Date: ^ <br /> --'FOR DEPARTMENT USE ONLY <br /> K�A . <br /> Application Accepted by __`-_"___C�.a.j+bt ._._ 3— ^, � Date —7 Area <br /> r <br /> Ph or Grout irnpectbn by Date Final Inspection by ` Date <br /> OTS2�i?_iAdditional Comments: � m4 <br /> ,. <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 Ell <br /> MOUNT DUE. AMOUNT REMITTED :CA <br /> HEM 13-24 IAEV.i N W ' <br /> EH N•]0 � y Sass 7 <br />