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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 /> PE_HMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application Is hereby made to Sm 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 /> Job Address. q-355 a / r City Lot Size/Acreage �! <br /> Owner's Nams w 9355-0) <br /> • r r w`7 � P{to� y <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well L7 <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 /> O Industrial O Open Bottom O Manteca Ole. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> — <br /> M Pnbtic I:1 Other O Delta Depth of Grout Seal Type of Grout <br /> — <br /> Q ImUstion Approx. Depth O Eastern Surface Seal Installed by <br /> Repair Work Done O Type of Pump. H.P. State Work Dona _ <br /> Well Destruction O Well Diameter Sealing Material a Depth <br /> Depth - Filler Material i Depth <br /> 1 <br /> TYPE OF-SEPTIC WORK;MNEW-INSTALLATION-0. REPAIR JADDITION --DESTRUCTION (No-septic-system-permitted'if-public sawair it— <br /> r• t•~!available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other t <br /> Number of living units: :Number'of bedroom <br /> Character of soil to a depth of 3 fe°e[ �'`^ t Water table depth <br /> SEPTIC TANK Typal Mfp• •° ' \ apacit,Y `��' No,Compartments <br /> fM6-'fAfAi�AEN'FPtrT.O �_ McBtod o1 DittposN <br /> Distance to nearest: WeN=S,[.L'�'Foundation fc, Property he <br /> LEACHING LINE P. No. 6 Length of linea Total length/sire 3 <br /> r 1 <br /> FILTER BED M Distance to nearest: Well 1049 Foundation 4,0 Property Line <br /> SEEPAGE PITS 11 Depth r 'Sire Number,. <br /> SUMPS LI Distance to nearest: 'Well Foundation Property Line <br /> DISPOSAL.PONDS O \7— <br /> I <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 Z '. <br /> Home owner or licensed agent's signature canities the following; '9 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 Iowa of California.'-ConRactor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the workfor which this permit is issued, I shag employ persons subject to workman's compensa. <br /> lion laws of ifomla," _ I— ^� <br /> The applicant s all l r uirsd�insgpe_ctions. Complete drawing 'un reverse aide <br /> Signed �'`u'��R Title: t - `Jl,pn� • - Date: A0 ,m -go <br /> FOR DEPARTMENT USE ONLY //�i�t ['''' <br /> APPli6i tion Accepted by 1 /%i�R t i Nov Dots /J L9 'd Arae <br /> Pit or Grout Inspection by Date -Finat-Inspection_by_ JZ;QDate <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 2000, STOCKTON, CA 95201 <br /> 4Nf0"—AM1O`UNTT-DDUEE_—..-AMOUNT-II�EEMyyi��TT.ED__�K -- _- 11ECEIVED.BY - _DATE �y-+PERMIT-NO.- <br /> j Ey 17141AIV."Ad <br /> 11` vl.l <br />