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APPLICATION FOR PERMIT ---- —--- "_- <br /> SAN JOAQUIN COUNTY PUBLIC HRAI,T �C <br /> ENVIRONMENTAL HEALTH DIVI ION <br /> 445 N SAN JOAQUIN, PHONE (209) . <br /> P O BOX 2009, STOCKTON, CA0 <br /> �= rLl # <br /> PERMIT MIMSpY �f{Complete in Triplicate '- � <br /> Application is heroty sailda to Bap Joaquin County for a permit to construct andlor install the work herein described. This <br /> application to w,4e in compliance with Bap Joaquin County Ordinance go. 549 antl 1862 s.ttd tete Rules and Aegulations of Ban <br /> Joaquin County YuDLic Health services. <br /> Job Address -20 SIR In. �cZ "�a_ City Lot Size/AcrewAe ;- <br /> Owner's Name k: [ CLAddress /95 2. 5- _s V7 <br /> Contraclor {i __Address.`y-7!`, �(�1'D /L� License Noma Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r DESTRUCT(0N ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION C SYSTEM REPAIR )r OTHER C3 Monitoring Well C1 <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 /> Ll Industrial 0 Open Bottom ❑ Manteca Pie. of Wei!Excavation_ Dia of Woo Casing <br /> (1 Domestic/Pftvate 0 Gravel Pack 0 Tracy Type of Casing Specifications Q <br /> I'1 Ptibilic IST Other f"1 Delta Depm of Grow Sea! Type of Grout <br /> ➢C1rrKiatron _Appros, Depth l Eastern Surface Seat Insto4od by <br /> Repair Work Dona Type of Pump Stats Work Dons <br /> Woo Destn,ebw O Wed Diameter Sealing Nateria.1 fi Depth <br /> Depth Filler Material i, Depth `h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f ! AEPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted it public cower is v� <br /> available within 200 feet.l <br /> Installation will serve: Res4ona— Commercial — Other <br /> Number of Irving units: Number of bedrooms <br /> Chatsctsr of sell to a depth of 3 tact: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Crxnpenn*nts �r <br /> PKG. TREATMENT PLT.❑ Method of Disposal (J' <br /> Distance to nearest: Well , Foundation Property Line tr <br /> LEACHING LINE D No. 8 Length of knot y Total length/size <br /> FILTER BED Cl Distance to merest: Wee foundation _ Property Line <br /> SEEPAGE PITS 11 Depth Sire Number _ <br /> SUMPS LI Distance to rawest: Wel _ Foundation Property Line ` <br /> DISPOSAL PONDS O <br /> 1 hereby certify that I have prepared this application and that the work will be dons in accordance with San JLvquin county ordinances, state laws, and <br /> rules and rogulattom of the San Joaquin County <br /> Hong owner or licensed agent's signrturs certifies the foflonnng; "I certity that in the performance of the work for which this permit is issued, I shall not <br /> empty any person in such manner.s to become subiact to workman's compensation(aws of California-"Contractoi%hiring or sub-contracting signature <br /> cartifies the folow»g: ")certify that in the performance of the work for which this permit is iswed.I shell employ persona subject to workman's compensa <br /> tion laws of California," <br /> The at c for Oi required inspections. Corrosre drawing on top side. <br /> Siprnd � Title: � 02 Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> .' <br /> Applic~Accepted by Dote Area __ <br /> Pit or Grout Inapactbn by to Final Inspection by 0 Data C L v <br /> Additional Commenw: <br /> Applicant - Return all copiee to: Sen Joaquin County Public Health 8ervicee <br /> C/ Environmental Health PenoitiServicea r''� /1 n n <br /> blJ 445 N San Joaquin, P O Box 200-9, Stkn, CA 5201 \ A 1 V\040 <br /> IFfE AMOUNT DVE' AMOUNT REMITTED CASH RECEIVED BY _J " MIT'NO. <br /> Cit,>Ntftew „e i� <br /> EM if•al <br /> z♦ <br />