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P. <br /> APPLICATION FOR PERMIT A <br /> U <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PLU11 EXPIRES I YE ERIOV DATE ISSUM <br /> (Complete in Triplicate) i'A H"Al T1 1 <br /> wor <br /> the ­k-,1i:"Ae` ,Ai1Td dtewcr�: <br /> Application Is hereby made.to San Joaquin County for a permit to construct and/or install the <br /> application Is Made in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules I&nd Regulatione of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acre&ge <br /> Lbuis e- <br /> Owner's Name75/ Phone 4 <br /> -y Address <br /> E. rffe, <br /> 'Spec UM CW 15_e5b0_r License NoAVZZ4-.� <br /> Contractor 11�r Address Phone <br /> TYPE OF WELL/PUMP- NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0.out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER�;el 50 itor' We`�.l <br /> >50 ;P_fio — Pr&IIEMS/ C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES — DISPOSALFLD **050 PROP.OP. LINE_ <br /> FOUNDATION AGRICULTURE WELL ?�� OTHER WELL PITSISUMPS ZED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Die. of Well Casing <br /> I <br /> Cj Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing-___-:— Specifications <br /> �ErnM Public 11 7 Other 0 Delta Depth of Grout Seal Ty !of Gi !e7i <br /> CJ Irrigation —Approx. Depth 0 Eastern Surfice Soul Installed by e, ./77I (� <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction 0 Welt Diameter Sealing Material A Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIRIADOITION M DESTRUCTION M (No septic system pe'rmitted if ptiblic sewer is <br /> available within 200 feet.) <br /> Installation will serve: -Residence — Commercial— Other <br /> Number of living uniis., — Number of bedrooms <br /> Character of soil to a depth of 3 feet: ----Water table depth <br /> SEPTIC TANK 0 Type/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation— Property Line <br /> LEACHING LINE 0 No. & Length of hnes Total length/size <br /> FILTER BED 0 Distance to nearest. Well Foundation — Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinance$, state laws, and <br /> rules and regulations of the San Joaquin County I <br /> Home owner or licensed agent's signature canities the lollowing: "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 <br /> 0 come <br /> subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify th, n llh�'—Zemancs of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws f C <br /> f or <br /> The appli 0 all ad inspections. late drawing on reverse side. <br /> �.eed inspections. <br /> _I , <br /> .14 AIYA <br /> Signed a <br /> C�P "I CoZ� Title! I <br /> < <br /> 9 DEPARTMENT USE ONLY <br /> Application Accepted by Oat" Area <br /> Pit or Grout Inspection by Date Final Inspection by n6�4t . ,. P-24::)-_1F1 <br /> Additional Comments; ZZ I <br /> Applicant Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 443 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE <br /> INFO "A <br /> AMOUNT DUE AMOUNT REMIT71ED CASH <br /> REC9VEO BY OATE PERMIT'No, <br /> • tH <br /> EM �4.26 361 <br />