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APPLICATION FOR PERMIT ` 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> L{ PERMIT. E%PIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> jApplication is hereby made.to Sen Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San <br /> Joaquin County Public Health Services. y-�,-� <br /> Job Address-a, 1� co eqe � City Lot Size/Acreage <br /> 93/ <br /> + �2L(L �-!CJ--- <br /> Owner's Name � Address , Phone <br /> r � <br /> Contractor `v � ddress LC242a 1161�.�..6212 License No. Phone <br /> [+ TYPE OF WELL/PUMP: " NEW WELL)' - WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATIONW SYSTEM REPAIR ❑ tOTHER ❑ Monitoring W�r11 n <br /> DISTANCE TO NEAREST: SEPTIC TANK " -SEWER LINES DISPOSAL FLD. ' PROP. LINE AE f <br /> t. FOUNDATION S/ AGRICULTURE WELL '� OTHER WELL � PITS/SUMPS r <br /> r + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �f 0 Industrial ❑ Open Bottom 11Manteca Dia. of Well Excavation__ _f Dis. of Well Casing <br /> F4 1 woomesiWPrivato Gravel Pack ❑ Tracy Type of CasingSpecilications ld-Z2 <br /> I"1 Ptablie Over 11 Delta Depth of Grout Seal Type of Grout--� <br /> I I Irrigation App(ox. Depth i I Eastern Surf a a Sett Installed by 1421e=1144 <br /> 6 <br /> Repair Work Done U Type of Pump H.P. L ?- State Work Done <br /> Welf Destruction ❑ Well Diameter Sealing Material & Depth <br /> DepthFiller Material Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I: DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> " Inst"N"M' wilt serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC BANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.:TREATMENT PLT. ❑ _ Method of Disposal <br /> Y Distance to'nearest: Well Foundation Property Line <br /> t <br /> LEACHING LINE ❑ No. b Length of lines Total length/size <br /> FILTER BED © Distance to nearest: Well Foundation Property Lin* <br /> ne <br /> I <br /> # SEEPAGE PITS I I Depth Size Number <br /> FSUMPS LI Distance to nearest:LL Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hsrsby'conify that I have prepared this application and thit the work will be done in sccordancq with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's igignalure certifies the follow_ ing: "I certify that in the performance of the work for which this permit is issued, 1 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 /> I <br /> cortifies the fogowing:"I certify,that in the performance of the work for which this parinit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appiican a uir Complete drawing an ravens ids." <br /> F1' <br /> Sg+ Date. S �d <br /> F IR DEPARTMENT USE O LY <br /> APPtcaton Accepted b <br /> y ��,, ��._ �4-�,� :Data ��r�� Arae Q ,. �Z <br /> T Inspection b <br /> Pit or Cyl 44G '"D 99 ate 2„_ Final Inspection by--f �� <br /> Additional Comments: . <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> 1 Environmental Health Permit/Services <br /> 445 N San Joaquin; P O Sox 2009, Stkn,' CA 95201 <br /> INFE AMOUNT DIE AMOUNT REMITTED C K If RECEIVED BY DATE PERMIT'NO, Q <br /> i• EM t3"t4 IREv.i i�e� W r� d �Q /7�`- /� 3�0 <br /> EN 1671 <br />