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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 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 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 vork herein described. This <br /> application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public�Health /Services. h <br /> Job Address 3� 9S /t �R� kc/ City 5-ro rOL-' Lot Size/Acreage <br /> Owner's Name C'�ZOP�,e earter Address Jl._�'Ih e Phone r3 DU <br /> ConIracCor /;Aol-, 2c Address'A"e')" X1/3 License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring well O <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 /> C7 Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [] Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> I1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I litigation _Approx. Depth I I Eastern Surface Seal Installed by �(\ <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth �J <br /> Depth Filler Nat ial i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONI DESTRUCTION I I (No septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial _�_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 fest: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg <41-vC/z c Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE (/No. 6 Length of lines 1" so Total length/size <br /> FILTER BED O Distance to nearest: Well /0-1p' Foundation fa Property Line /0 <br /> SEEPAGE PITS j.1- Depth _5 Si:e d'" Number <br /> SUMPS LI Distance to nearest: Well !v4i Foundation /u Property Lina w <br /> DISPOSAL PONDS O <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 subject to workman'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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for all requ' inspections. Complete drawing on reverse ide. l <br /> Signed L Title: i� Date: <br /> A FOR DEPARTMENT USE ONLY <br /> Application Accepted by � ^`Y� .� 1Data L t- Area D Z <br /> �•_► <br /> Ph or Grout Inspection by Date Final Inspection by A/ADate 1' <br /> Additional Comments: a Lke-� /(0r -�A- <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED/BV DATE PERMIT'NO. <br /> . EH134 (REV.r i 8 al / r T-7 <br /> EH 11.711 S2 c0 <br />