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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT ERPIRF3_ 1 YEAR FM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application In hereby made to San Joaquin County for a permit to construct and/or install the ►cork herein described. This <br /> application Is made in coWliance 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 / / - City Lot Size/Acreage 1 <br /> � <br /> Owner's Name �52Z Address �� Phone <br /> . w, <br /> Contractor S A dress ���License No. al�Phone <br /> TYPE OF WELL/PUMP. NEW WELLX WELL REPLACEMENT n DESTRUCTION A Out of Service Well ❑ <br /> PUMP INSTALLATIONt SYSTEM REPAIR ❑ OTHER p Monitoring 1 Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES DISPOSAL FLD '' <br /> :-- PROP. LINE L�� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .Lan <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Oia. of Well Casing <br /> Dpme;Iic/Private XGraval Pack 0 Tracy Type of Casing 102eK_ Specifications i <br /> ❑ Public 1l her ❑ Delta Depth of Grout Seal_ Type of Grout <br /> CJ Irrigation L.Approx, DispO7 0 Eastern %-��Surface Seal Installed by <br /> Repair Work Done U Type of Pump -�2 H.P. State Work Done <br /> Wall Destruction D Well Diameter Sealing Material i Depth <br /> Depth Piller Material i Depth r_ <br /> TYPE OF SEPTIC WORK, NEW INSTALLATION 0 REPAIR/ADDITION Cf DESTRUCTION G INo septic system permitted if public sewer is �1 <br /> available within 200 loot.) �Q <br /> Installation will serve: Residence— Commercial— Other <br /> 'r <br /> Number of living units: Number of bedrooms y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Property Line <br /> LEACHING LINE Cl No. 8 Length of lines Tonal iengthlsize t <br /> FILTER BED n Distance to nearest: Well Foundation Property.Line <br /> 1. <br /> SEEPAGE PITS 11 Depth Siie Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` r <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 I ; <br /> Home owner or licensed agent's signature certifies the following:"II 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 or sub-contracting signature I <br /> certifies the following: "I certify that in the perfofmance.of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Iowa o1 California." - <br /> The applicant t II uired.ita Qe mpiete drawing on reverts side. <br /> Signed K Date: <br /> FOR DEPARTMENT USE ONL t!1 <br /> Application Accepted by t� Date o ~,7 ~ID Area ? /r <br /> Pit or Grout Inspection by �� `"� Date Final inspection by S 2vw DateZ L7 <br /> Additional Comments: �C `U 2-12-(o <br /> Applicant - Return all copies to: SAI{ JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P,O -BO% 2009,. STOCKTON, CA 95201 <br /> rFEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, <br /> EH 13.24 TREY.I/MS) C-,---gag <br /> EH;�•Zb <br /> 9- -7'74c <br />