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APPLICATION FOR PERMIT <br /> " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 'i ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 o(60 <br /> �f <br /> P�S�iT FEAR FROM DATE ISSUE) U <br /> (Complete in Triplicate) <br /> Application Is hereby made'to San 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 of San <br /> Joaquin County Public Health Services. <br /> Job Address City too Lot Size/Acreage _- <br /> Owner's NameAddress re u / <br /> -'� ` A' 22 Phone 41q.V-2ilL <br /> Coniraclo( �� `.� Address i` License No. Zbt 7010 - Phone �- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f7 DESTRUCTION ❑ Out of Service well 11 <br /> PUMP INSTALLATION U SYSTEM REPAIR ❑ OTHER 0c,' Z. tirell L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LIINNEr <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPCCIFICATIONSI ff <br /> Ll trial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public I') Other ❑ Delta Depth of Grout Seal Typ of Grout <br /> Cl Irrigation —Approx. Depth © Eastern Surface Soul Installed by f <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction 0--well Diameter- Sealing Material 4 Depth O op <br /> Depth,. jc r _ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION 0 DESTRUCTION G (No septic system permitted-if public sewer is <br /> 'l available within 200 feet.l <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: <br /> Water table depth <br /> SEPTIC.TANK. <br /> � ❑ Typa/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Q No. 8 Length of lines Total length/size <br /> FILTER BED CI Distance to nearest: Well" Foundation Property Line <br /> SEEPAGE PITS 11 Depth Silo Number <br /> SUMPS Ll 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 comity 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 becomo subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: -I mify that in the performance of the work for which this permit is issued, I shrill employ persons subject to workman's compenss- <br /> i tion laws of Calif i1 <br /> The applie must f rr uved inspections. Complete drawing on reverse side: <br /> i <br /> _ c ' <br /> Signed I <br /> .F Title: Data: � ,_.__� <br /> ;IF DEPARTf4MENT USE ONLY <br /> Application Accepted by <br /> Date / � � Area <br /> ii <br /> Pit or Grout Inspection by Date Final.Inspection by_--. / Date �� <br /> Additional Comments: (9, �d�k. � � .r- <br /> 1 <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, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMiTTEO CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASK <br /> . EH .28 nEy.kiNS! d0 q .e,a /d1gS sm M' ?•�, �t -i�S� <br /> EM A;{•2e <br />