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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 /> I'g 13: L01REG 1 YEAR P99M AA• E ISSUED <br /> (Complete in Triplicate) , <br /> Applicstioa is hereby made to San Joaquin County for a permit; to construct and/or install the work bereia deserlbed. This I <br /> application is shade in ca*liance with San Joaquin county Ordinance No. 549 and 1662 and the Rules and Regulations of Sara I <br /> Joaquin County Public Health Services. <br /> Jab Address . Al-✓ City ._ trot $ 1tit reage <br /> oof71= <br /> Owner's Nam. Jr JTf Address _ Phone �w <br /> ContraCta � .rr ddress License Na 4�� Phoned <br /> TYPE Of WELL/PUMP. NEW WELL ' WELL REPLACEMENT n IDES TRUCT10 t of Service Well G <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLP. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WftL PROBLEM AREA CONSTAUCTION SPECIFICATIONS <br /> Li industrial O Open Bottom O Manteca Mo.of wall Excavation Dia. of Wall Calling Via*OomesirclPrivate 0 Gravel Pack 0 Tracy Type of Caning SpeciltCations „i <br /> *Public 1:1 Other O Doha Depth of Grout Seal Type of Grout <br /> M Irrigation _Approx. Depth D Eastern Surface Soul Installed by <br /> Repair Work Done U Type of Pump H P. State Wort Done_ <br /> Well Destruction AV Wall OwrIator sealing Material i Depth �- <br /> Depth, Yillrr Material L Depth � ��r ���.�+� ��► <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION A REPAIR/ADDITION CI DESTRUCTION CJ INo septic system permitted if public sawar is <br /> ay$Asble within=0 tae I <br /> Instillation VAN serve: Residence_ Commercial— Other <br /> Number of living sings: Number of bedrooms <br /> Character of$00 to a depth of 7 fort: Water table depth ! <br /> SEPTIC TANK O Type/Mfg Capacity No. Comportmants <br /> PKG, TREATMENT PLT,0 Method of Disposal <br /> Distance to tr►enst: Well foundation Property Lina <br /> LEACHING LINE Cl No. & Length of linas Total iength/size <br /> FILTER SED 1-3 Distance to nearest: Well__,,, foundstion Property Line <br /> SEEPAGE PITS I I Depth Size, Number. I r <br /> SUMPS Lt Distance to mwast: Well foundation Property Line <br /> DISPOSAL PONOS Cl v <br /> I hereby certify that I hove plapared this application and that the work win be done in accordance with San Joaquin county ordinances,stats laws, and <br /> rUW&and regulotiona of the San Joaquin County <br /> Home owner or licensed agent's signature Certifies the toiiowing: "I cortify that in the pariormance of the work tot which this permit is issued,t shall not <br /> employ any person in such manner,as to become subject to workmoh's compensation laws of California."Contractor's haring w sub-contracting signature <br /> t:ertifie&the following:"I Certify that in the pertorrrunCe of the work fa Which this permit is issued, I Shall employ persons subtsct to workman's computsa• <br /> tbn law&of California," <br /> The applicant &t ired' mpista dravrrng on revs ea }00, �, f <br /> Signed x �e _s✓ _ r' 'Fitts:_ `' _ .•--w 000, �"� I1� <br /> 101V <br /> FOR fSEPARtMENT USE ONLY .y ✓f <br /> Application Accepted by vuo b <br /> Pit or Grout Inspection byf, Date final lnspaalkfi by a <br /> Dat # �� <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIAO"ENTAL HEALTH DIVISION PERMIT/SERVICES \�J <br /> 443 N SAN JOAQUIN. P 0 Il= 2009, STOCXTON, CA 98201 <br /> FEE INFO AM�ogtlNt DtJE +nMOutr7 RfiMiTTEt7 CASH RECEIVE0 8Y DATE PERMIT NO. <br /> • tMtS•d1tflN.li�D� ,,,k l9,D'"v ` <br /> I <br />