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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 /> PERMIT .URIBB$ 1 YEAR ?R9X 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. 549 and 1862 and the Rules aad Regulations of San <br /> Joaquin County Public � �-�""'rHealth Services. <br /> Job Address 4g? / wgr — City Lot Size/Acreage <br /> Owner's Nameg� ` Address T Phone <br /> Contras Address License Phon ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Cl Out of Service Well Gl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11. Ind sl O Open Bottom ❑ !Manteca Dia. of Well-Excavation Dia. of Well Casing <br /> omestic/Private ❑ Grave! Pack ❑ Tracy Type.of Casing Specifications <br /> D Public -1 Other ❑ Delta Depth of Grout Se AI Type of Grout <br /> CJ Ifrivation _Approx. Depth ❑ Eastern I Surface Seal :Installed;by <br /> Repair Work Done Mr Type of Pump) H.P. 1 ?� State Work Done (� <br /> Well Destruction O Well Diameter` Sealing Material i Depth 6 1 <br /> Q <br /> Depth = Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION n REPAIRIADDITION 0 DESTRUCTION M (No septic system permitted if public sewer is <br /> available within 200 leet.j <br /> Installation will serve: Residence— Commercial— Other ' - <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compamments <br /> PKG. TREATMENT PLT, ❑ "''O--' z '. Methodgyo�fI - t <br /> Distance to nearest: Well Foundation Prope��n�!!kS � '�• <br /> � " (� <br /> oEeFuVIED <br /> LEACHING LINE 0 No. & Length of lines Total length/siiz� <br /> FILTER BED n Distance to nearest: Well Foundation PropeYT kin <br /> i 601 jngjum <br /> SEEPAGE PITS 11 Depth ' Size Nuifsbe;D I1EA1 iC, N <br /> SUMPS LI Distance to�;nearest:—WeH., Foundat;an <br /> DISPOSAL PONDS ❑ <br /> I hereby comity 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 Sart Joaquin Countyi v . .-P. -0 �,-,,ti. _ <br /> Home owner or licensed agent's signature cemifies the following: "l dertify 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 subcontracting signature <br /> certifies the following: "I certify that in the pefformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion taws of California." <br /> The applicant 1811 rs uirad:ins ctions, Complete drawing averse side. <br /> Signed Title: _„_--_-- Date: <br /> FOR DEPARTMENT USE ONLY <br /> ^Application Accepted byDate �Z Rraa _ <br /> Pit or Grout Inspection by Date Final Inspection by ate C7 �7 z- <br /> Additional Comments: i1 <br /> Applicant - Return all copies to: jSAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> fENVIRONMMTAL HEALTH DIVISION PERMIT/SERVICES <br /> j445 N SAN JOAQUIN, P O BQX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE # AOUNT REMITTED. 'CK RECEIVED BY DATE PERMIT'N0. <br /> INFO r ` ,_ � ` <br /> 1 <br /> r <br /> EH 113-24 Yr`? (J7/ 1 ?2 -2(V7/1 <br /> Eli 3/-�s r <br />