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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 /> PERMIT U2IRES 1 YEAR PROM DATE ISSUED <br /> (Complete in Triplicate) <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 County Ordinance No. 549 and 1862 and the Rules and Regulations of San � <br /> Joaquin County Public Health Services, <br /> Job Address ����f� / ��rCity Lot Size/Acreage <br /> el"Ao�pwle 10 <br /> Owner's Name �4f�1 / 6?�Lv 1R_/?i Address �- r f�"�/V.� Phone <br /> l <br /> Contractor cS Fwof <br /> dres'�,��`/_ � e �—License No.; ' rr2 Phone <br /> TYPE OF WELL/PUMP: NEW WELLX WELL REPLACEMENT n DESTRUCTION Out of Service Weil ❑ <br /> PUMP INSTALLATI[ON>1t SYSTEM REPAIR 0 OTHER O Monitoring well r <br /> DISTANCE TO NEAREST: SEPTIC TANK --�l�L�-- `SEWER LINES '" r DISPOSAL FLD:: PROP. LINE 1.o f <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> C] Industrial O Open Bottom O Manteca Die, of Well Excavation Dia. of Well Casing <br /> ,TQ Domestic/Private 'Gravel Pack O Tracy Type of Casing_ Specifications f� <br /> M Public1/0�her O Delta Depth of Grout Seal _Type of Grout 7 _ <br /> M Irngatlon J_/Appfox, Depth CI Eastern S 1 dice Saul Installed by <br /> Repair Work Dorn U Type of Pump H.P. - - State Work Done_ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth r_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION M DESTRUCTION Cl (No septic system permitted if public sewer is <br /> available within 200 lest.! <br /> Installation wig serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of&oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLL M Method of Disposal <br /> Distance to nearest: Welf Foundation'` Property Line <br /> LEACHING LINE CI No. &Length of lines Total length/size l <br /> FILTER BED Cl Distance to nearest: Well Foundation Property.Line <br /> SEEPAGE PITS 11 Depth Size - Number <br /> SUMPS LI Distance to nearest: WON foundation Property Line <br /> DISPOSAL PONOS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and regulations of the San Joaquin County i <br /> Home owner or licensed agent's signature certifies the lollowng "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 perfor'mance.of the work for which this permit is Issued,I shall employ persons subject to workman's compansa- <br /> tion laws of California." <br /> The appkcartI t II I iredanspe mpiets drawing on rover side. <br /> Signed itis: ��/ - Date: le <br /> ll 7 1,4;74 <br /> A/W FOR DEPARTMENT USE ONL " <br /> Appilcatlon Accepted by t. Date Ae ~'7_ Area /r <br /> Pit or Grout Inspection by �/' Date Final Inspection by )�==- :`�' G rL Date 7 Cf <br /> / -� r <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 2000, STO"TON, CA 85201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED By DATE �PERMIT2NO, <br /> EH t3 it]REV.I1 M 7 y 5) G�� /'�' / ©sur V <br /> FM!1•=a <br /> c:1 -7 ? <br />