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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAC.HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I Y FR M— DATE 5 <br /> (Complete in Triplicate) <br /> 1I <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin CountyOunce No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> r, LotG �Av City /`��� t Size/Acreage <br /> Job Address . <br /> j� ' - Address Phone <br /> Owner's Nam r - 7,yG <br /> tea <br /> Contractor cK L�Address,3 �'&ox License No S Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service well Q <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE — ?W--�. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 <br /> _ INTENDED USE ``TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ;C Industrial { ❑ Open Bottom El Manteca pia. of Well Excavation - Dia. of Weil Casing a(� <br /> C7 Domestic/Private ❑ Gravel Pack7 El Tracy Type of Casing Specifications � <br /> I'1 Public, rl Other FI Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation^a� Approx.Depth 'I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Dons <br /> Woo Destruction O Well Diameter Sealing Depth <br /> Material i <br /> Miler Material iDepth <br /> Depth - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIO DESTRUCTION I !Na septic system permitted if public sewer is <br /> available within 200 feet.l <br /> .Installation will serve: Residence— Commercial:Commercial Other <br /> Number of living units: Number of bedrooms <br /> E ' Character of son to a depth of 3 fest: Water table depth <br /> SEPTIC TANK. Type/Mfg. Capacity No. Co of Disposal <br /> PKG. TREATMENT PLT.Q a ' r Method of pisposral r?k, <br /> Distance to nearest: Well A10$4� Foundation s Property Line V <br /> r <br /> F LEACHING LINE No. A Length of lines �[�;,/ . Total length/size I " <br /> FILTER SEDT Distance to nearest: Welt Foundation Property Line <br /> � SEEPAGE PITS .I►!''�Depthf Size P41 - 40 Number <br /> SUMPS LI Distanto nearest: Wall Akn,LFoundation� Property Line <br /> ce <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 iignature 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 of 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 compensa- <br /> tion kiwi of Cdiforn .' <br /> The applicant, all for ai 'ad inapec' a. Complete drawing on re arse side. <br /> 1 Title: Date:8 <br /> Signed <br /> 40 ' FORD ENT USE ONLY <br /> Date <br /> i Application Accepted by f• '�^ ` Z— Area Y Z <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additions! Comments: r14 �. f�[sY <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> I FEE AMOUNT DUE AMOUNT EMITTED ACCEIVED BY DATE PERMIT'NO. <br /> INFO 1 <br /> • EM 1.1-24 IrIEV.f/M 61 �� �/ / r % �J <br /> EH 14.20 •K !s//L/,.o <br />