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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 /> r (Complete in Triplicate) <br /> t - <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 and Regulations of San <br /> I Joaquin County Public Health Services. <br /> ` Job Address City Lot Size/Acreage <br /> ` realZ2 eeW Phone <br /> Owner's Name <br /> Contractor ddress License No. Phone <br /> 91* <br /> ! TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION &rout of Service Well U <br /> tPUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER p Monitoring 41e11 ❑ <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 <br /> Open Bottom 0 Manteca Dia. of Well Excavation — Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack E3 Tracy Type of Casing_ Specifications <br /> I'I Public •' "Cl Ot_hei n.Delta Depth of Grout Seal Type of Grout <br /> G i I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done CJ Type of Pump H.P. St t4 W d D pg <br /> Well Destruction `°'Well Diameter Sealing Material i Depth if <br /> Depth ?° Filler Material i Depth , <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I I REPAIR/ADDITION (-) -DE51'RUGTION-1-JTiNo_septic:system permi d if public sewer is _ <br /> x ti available within 200 lest.) <br /> lnstalletio will serve:.-Residence Commercial,! Other <br /> Numbs of,iiGing units: Number of bedroomsk <br /> Character of wit to a depth of 3 feet: ? �• ° " Water table depth <br /> SEPTIC TANK. Type/Mips s Capacity '4 i No. Compartments <br /> PKG..TREATMENT PLT: 0Method of Disposal <br /> Distance to nearest: Well IFoundation-~�'� <br /> LEACHING LINE ❑ No. 6 Length of lines Total lengthtsize <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line k <br /> ' t � <br /> Y <br /> SEEPAGE PITS l I Depth Siie Number <br /> SUMPS f 41 Distancesto nearest: 'Well Foundation Property Line ' <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 A`�,.-11_ I �A I V- I <br /> Homs owner or licensed a'gent's signature certifies the following, "I comity that in the performance of the work for which this permit is issued, I shall not G <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 /> � eertifWs-the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman'ti;compensa- <br /> b of tion laws of Californla_:" � ,r' �V <br /> The applicant c o elf req!T ions. Complete drawing on raver�li�ths,:p <br /> Signed St <br /> . Date: <br /> FOR DEPARTMENT USE ONLY l <br /> it <br /> i Application Accepted by ; Date Area j <br /> Pit or,Grout Inspectlon by Date Fin Inspec'on by <br /> Date <br /> �•r+~`' � ____.�.-.•--.... - �/I� _ .�.f -_ --T•^•-.-.--4.._-�...=TT--" <br /> " """ '^Addis `Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> �''`�� Enyironmental�Hea:l.t•h Perm t/Services <br /> '" 445 N San:Jotquin-;­--P.O-Box12009, Stkn, CA 95201 <br /> CK 8FEEINFO AMOUNT DUES' AMOO�UNT REMITTED CASH RECEIVED BV DATE AERMIT'NO. <br />