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APPLICATION FOR PERMIT <br /> R # <br /> SAN j.yAQUIN COUNTY PUBLIC HEALTH <br /> EAL <br /> ENVIRONMENTAL HEALTH DIVIS ES� � �✓ <br /> 445 N SAN JOAQUIN, PHONE (209)tg8AM <br /> i P O BOX 2009, STOCKTON, CA W <br /> Co <br /> PERMIT T EXPIRES 1 YEAR-FROM DAT <br /> (Complete in Triplicate <br /> Application is hereby* mode to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in coupliance 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 1_ 3d �" h _ City Lot Size/Acreage SDS cLrJl��� <br /> FOwner's Name - Address _<< 0,A,,( 95-4 hone `���/-VIM <br /> Contract �G a, Address rt �� License No� PZL& Phone &SS` g <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Privam ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Pt►blic n Other 11 pelta Depth of Grout Seal Type of Grout <br /> t I Irrigation - _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. Statq Work,Done <br /> I W&P Destruction ❑ Well Diameter Sealing Material A Depth <br /> Depth 1111er Material i Depth N <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I i ;No septic system permitted if public sower is L�,N <br /> available within 200 feet.) X <br /> r Installation will serve: Residence Commercial_ the <br /> Number of living units: __.L..__. Number of wroomy, /y <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. >d Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O / ! Method of Dia9oSal <br /> Distance to nearest: Well t Foundation !sf Property Line y5 <br /> LEACHING LINE t`^ No. 5 Length of lines _ 2 - AdQ Total length/size <br /> * FILTER BED ❑ Distance to nearest: Well D! Foundation 11Q i_ Property Linef <br /> SEEPAGE PITS I I Depth Size Number <br /> # SUMPS LI Distance to nearest: Well Foundation Property.Line C <br /> DISPOSAL PONDS ❑ rtt <br /> r I hereby certify that 1 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 /> j 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. I 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 /> 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 compenss- <br /> tion laws of California." <br /> The applies at coq f yiird inspections. Complete drawing on reverse <br /> �djo C7 <br /> Signed 'Title: _ _ !rte _ _ Date: 42C D <br /> FOR DEPARTMENT USE ONLY <br /> Apptica[lor►Accepted by 4KDats Area <br /> 'a.r Ph or Grout Inspection by Date Final Inspection by Date t3 <br /> _ <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> f Environmental Health Permit/Services <br /> 1 445 H San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT OVE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 4 14-M�H t3-xarrtty.„SSI /`� •t`_Tr� P . 3S <br />