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. 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 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 work herein described. This <br /> application is made in coaWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. //�1 /,, <br /> Job Address 1S-0 N• Sinc/AiA / rVE' City yLZ� Lot Size/Acreage <br /> m <br /> Owner's Nanta // �/,>GJ Addr77 ,,rr �'��/YJLl - Phone <br /> Contractor Gloss Lt yry S Address.35-7 yy. L,,i Goll "" / License No.$�O�v7Z Phone s--20 y& <br /> TYPE OF WELL/PUMP: NEW WELL ❑1 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION fd SYSTEM REPAIR Xi OTHER ❑ Monitoring Well <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 /> * Industrial 5 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing i�z PyL— Specifications <br /> Q Public I1 Other ❑ Delta Depth of Grout Seal Type of Grout A <br /> ❑ Ifngation _Approx. DeEastern Surface Sial Installed by <br /> Repair Work Dona U Type of Pump H.P. 3 la Stat* Work Done ldc..�t �-CdZ 4 <br /> Well Destruction ❑ Well Diameter Sealing Material L Dept <br /> Depth Piller Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION ❑ DESTRUCTION CI (No septic system permitted it public sewer is C <br /> available within 200 lest.) <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, I shall employ persons subject to workman's compensa. <br /> tion laws of California." <br /> The applicant m t call f required inspections. Complete drawing on reverse side. <br /> Signed Xj� �""�--_'-�� Tide: ( J.C..i----¢—� Deter ,, <br /> ^.I\t1 FOR DEPARTMENT USE ONLY q <br /> Application Accepted by r^�f-w � � Date <br /> Pit or Grout Impaction by Date Final Inspection Date <br /> ,25-9 <br /> Additional Comments: _ <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCXTON, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE <br /> . EH I7 241REV.11x51 ch .0� /d� I l 19 �im <br /> EH :11.20 ✓ <br />