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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM 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 to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publi^ Health 8 vice t <br /> I <br /> Job Address i�T / CityLot Size/Acreage <br /> Owner's Name Address 124✓1r4a,47Lt*4 Phone <br /> r <br /> Contractor rens I �� �//_ License No. PhonePhone 7 2 <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Fl DESTRUCTION Cl Out of service Hell O <br /> PUMP INSTALLATION O SYSTEM REPAIR U OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - D SAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WEIR. OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR 10 SPECIFICATIONS <br /> (l Industrial U Open Bottom O Manteca Dia. Well Ex ovation Dia. of Well Casing <br /> (I <br /> Domestic/Private D Gravel Pack O Tracy of Casin Specifications Q <br /> I'1 Public f-1 Other rl Delta Depth of Gr t Seal _ Type of Grout � <br /> 11 frnuation — Approx. Depth I I Eastern Surface Se Installed by <br /> Rspeir Work Done U Type of Pump H P. State Work Done _ <br /> Wall Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 lest.) <br /> Installation will serve: Residence Commercial Other _ <br /> Number of living units: Number of bedrooms_ <br /> Character of soll to a depth of 3 feet: OQ ocl Water table depth <br /> SEPTIC TANK O Type/Mfg JL ¢ Capacity No. Compartments <br /> ir <br /> PKG. TREATMENT PLT. O CLE) <br /> r^� Method of Di al <br /> Distance to nearest: Well J [/L FoundationAp- Property Line ' <br /> LEACHING LINE Ll No. 6 Length of lines _ To I length/size <br /> FILTER BED O Distance to nearest: Well Foundation C) Property Line <br /> SEEPAGE PITS 11 Depth Z) Size _._ ,� 1/yumtber <br /> SUMPS LI Distance to est: Well�Q1W <br /> Foundation - Property Line <br /> DISPOSAL PONDS „ O <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 signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell 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 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 st call for al ired inspe tions. Complete drawing on reverse side. <br /> Signed Title: 1.'�1.L-7 r Date: <br /> y!9-�3 <br /> FOR DEPARTMENT USE ONLY / <br /> Application Accepted by iie _/ Area <br /> � t for Grout Inspection by 1 Date 7 \Final Inspection y Data j <br /> —Additional Comments: r <br /> ApplicRnt - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED ay DATE PERMIT'NO. <br /> r7 ell C,1 <br /> FN 14 2a <br />