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7-1- <br /> APPLICATION FOUR 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 EUTAES 1 YEAR ISR M 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 and Regulations of San <br /> Joaquin County Public Health Services. <br /> 0 <br /> Job Address 19 `-'� �� �U nf d Id le 9 Citya�i Lot Size/Acreage <br /> �283d Toga <br /> Contrattorl"[ 3/sqo� <br /> Owner's Name i! Address {*y W) - Phone q <br /> � 'e � �� Address c, i S 1 OS'S{0s • License No.,�..z.�M6 Phone �G <br /> _.... <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out or Service Well El <br /> PUMP INSTALLATION C3SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� i <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 /> L71 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation " Dia. of Well Casing <br /> Domestic/Private 'Gravel Pack 0 Tracy Type of Casing—( Y90 UC U-1 0 Specifications <br /> M Public �11''OIther 0 Delta Depth of Grout Seal r'�C - Type o out <br /> M Irrivation 2z&!.Approx. Depth, ❑ Eastern Surface Seal Installed by t' <br /> Repair Work Done 0 Type of Pump SlAh H.P. � State Work Done_ V <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.0 REPAIRIADDITION ❑ DESTRUCTION F-I (No septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <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 Foundation Property Line <br /> t <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Wolf Foundation Property Line <br /> DISPOSAL PONDS 0 <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 mqufations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, t 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 performance of the work tot wtiich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for all re ed inq2qCtions. Complete drawing overs�,de, <br /> Signed K Title: Date: <br /> 3- /J -V <br /> FfJii DEPARTMENT USE ONLY IIli <br /> Application Accepted byL Date 3 L Area_ 2 <br /> Pit or ro Inspection by Dater��. Final Inspection by� Date U �` G <br /> Additional Comments: — <br /> Applicant - Return all copiers to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 SOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CtCIf INFO CASH RECEIVED BY DATE PERMIT NO. <br /> p <br /> rEH17.24IREV.t/KSI INi.�4'� 9 [ , <br /> EH :4.7a 1 l <br />