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s 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 /> PENIT EMIREO DATE =UED <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 cempliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servi�es. <br /> 71' <br /> v. `Lot Size/Acreage <br /> Y 12C <br /> Job Address <br /> City <br /> Owner's Name Address Phone <br /> o <br /> ac o k Tt�c�tHo�oy_y 1�+A`ddress vtcc*� C 5 License Ivd: ?-G�_Phone <br /> L ..:ar1W' <br /> TYPE OF WELL/PUMP: '-S NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION^❑ out of Service Well Cl <br /> PUMP INSTALLATION .❑ SYSTEM REPAIR C7 OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK ll�cw- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONvt n), AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYI?.E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zbf <br /> 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing <br /> )�¢Domestic Privat ❑ Gravel Pack C1 Tracy Type of Casing 4 Specifications <br /> M Public Wu -K f ' 0 Otherm-LU,5timk 0 Delta Depth of Grout Seal 3�� _ Type of Grout <br /> G frogationkADepth ❑ Eastern Surface Seal tnstalled by <br /> Repair Work Done U Type of Pump H.P. InC y►'C State Work Done __i�jai, <br /> Will Destruction 0 Well Diameter Sealing Material i Depth -% <br /> Depth' Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION ❑ REPAIR/ADDITION 0 DESTRUCTION 0 (No septic system permitted if public sewer is <br /> available within 200 fest.1 <br /> Installation will serve: Residence— Commercial— Other v <br /> Number of living units: 6 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 /> i <br /> Distance to nearest: Well .Foundation Property Line <br /> s <br /> LEACHING LINE C1 No: & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property fine <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Disjance 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; 1 shall notes <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 spplic�&"ust callfor efl�ra4uirad as s, Complete drawing on.reyerse aide, <br /> Signed /!� [ � Tide: f/ to Date: a l <br /> i FOR DEPARTMENT USE ONLY <br /> �/ <br /> Application Accepted by _¢-Cy�� ... Oats 1� i 0 Area L-1Z e <br /> Pit or Grout Inspection by Date ?r/2z/ [q I Final Inspection by 1 Data L� <br /> Additional Comments: �Ce ��pp��� t �J�1•L�r-�� � - �'C r <br /> aS <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEAAV; ES"' �tF Y- C" �'TH �� <br /> ENVIRONMENTAL HEALTH DIVISION PERaIT MENTALHBALTH DIMSION <br /> i 445 N SAN JOAQUIN, P O BOX 2009, STOCKY N CA 5201 <br /> EFEE AMOUNT;IRUE AMOUNT REWTTEO CA$H RtcGEI JL • <br /> EH 13.24,>e .„Ps$, � °� V ��� —,�o -214 <br /> EN21 <br /> ,` <br />