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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON', CA 95201 <br /> (209) 468-3447 <br /> R <br /> (Complete in Tliiplicate) <br /> Application is hereby made.to San Joaquin County for a permit`to cmp ;onetruct and/or install the nark 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.IeAj City 70a Lot Size/Acreage J7X 341/ <br /> 0X2���� <br /> Job Address k � <br /> �0 Phone <br /> I Owner's Name m-a Address _ I' <br /> Contractor <br /> 4- pG 4PI�Address � • �� "" i�"' � JL� Ucense N9 Ll 1117J—Phone <br /> hone <br /> f ervice Well Ll <br /> TYPE OF WELL/PUMP: NEW WELL ID WELL REPLACEMENT 0 DESTRUCTION ❑ Out t4onitoring Well <br /> PUMP )NSTALCATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> i, <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 /> i n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia, of Well Casing <br /> F U Domestic/Private 0 Gravel Pack' ❑ Tracy Type of Ca sing Specifications - <br /> M Public Ci Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation —..App(ox. Depth 0 Eastern Surface S4o4ul Installed by <br /> Repair Work Done D Type of Pump H.P. 4 State Work Done _ <br /> 4 Depth <br /> Well Destruction © Well Diameter Sealing Material p <br /> Filler Ma,terls.14 Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEWINSTALLATION REPAIR/ADDITION L7 J�DESTRUCTION G fNo septic system permitted if public sewer is <br /> 4 available within 290 feet.) {� <br /> I <br /> Installation will serve: Residence' Commercial— Other <br /> Number of living units:':-- - Number of bedrooms -.3 7 <br /> Character of soil to a depth"of 3 feetr Water table depth <br /> SEPTIC TANK ;6I'f Typ#/Mfg C4apacky__/g?=_P4:P — No. Compartments Z- <br /> PKG.'TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina <br /> LEACHING LINE .0 No. & Length of linesw � Total length/size <br /> i <br /> FILTERBED n Distance to nearest: Well A( t Foundation �� Property Line <br /> SEEPAGE PITS 4-r'Depth 2-5Size i/ Number. <br /> �kI <br /> SUMPSI' Distance to nearest, Well !�' Found`tion ��t Property Lina 00'P <br /> DISPOSAL PONDS 0 1 <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 Sen Joaquin County <br /> 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 /> ompensation lawn of California." Contractor's hiring o+subcontracting signature <br /> employ any person in such manner as to become subject to workman's c <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 laws of California." <br /> ` The applicant mu or all requir ctions. plate drawing on reverse a <br /> Signed Title: + Date: - <br /> ' PARTMENi7 USE ONLY- <br /> Application Acceptediby I� Data j �3 V{ Area <br /> Pit or Grout Inspection by <br /> Date Fnal Inspection b Date <br /> ' 1 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2bO9, STOCKTON, CA 95201 <br /> il <br /> FEE AMOUNT pUE AMOUNT REMITTED CK RECEIVED BY DATE M-oris <br /> )NFO GASH "E n ih <br /> EM1 -24IREV.Iinsi IS . ,tea Qo��-7rn� t 'ry �_ l <br /> fH'J•26 r � w _ <br />