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ADPL I CATI ON FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 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 is made in cawliance 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 3 �✓ DL City r -1-4 Lot Size/Acreegge 7 <br /> Ownei s Name ? 1 Address ] C�f�.E}^ /�'!t� `pholn 6 <br /> Contractor O uJfl -- Address License No. Phone <br /> PE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT C DESTRUCTION Cl Out of Service Weil L7 <br /> PUMP INSTALLATiON.0 SYSTEM REPAIR C OTHER O Monitoring Well LJ <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 A E CONST &TION SPECIFICATIONS <br /> D Industrial D Open Bottom D Manteca` Die. Well Excavation Oia. of Well Casing <br /> El Domestic/Private D Gravel Pack n Tracy of Casing_ Specifications <br /> t'1 Public" C)Other D Delta a th of Grout Sea! Type of Grout <br /> I I Irrigation, _.Approx. Depth 1 I Eastern Surfs Seal Installed by <br /> Repair Worts Done LJ Type of Pump H.P State Work Done_ v_ <br /> Well Destruction O WeN Diameter n8 )taterial rpth LP <br /> i <br /> Depth Filler Material i Depth <br /> w TYPE OF SEPTIC WORK: NEW iNSTALLATfO REPAIRIADDITION DESTRUCTION I I fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation v%ill serve: Residence�___ Commercial_ Other <br /> Number of Wng,units: r-- Number ofbd4rooms 1 �7 <br /> Character of soli to a depth of 3 feet: Water table depth _�_ <br /> SEPTIC TANK $ Type/Mfg �- •Capacity db No. Compartments �- <br /> PKG. TREATMENT-PLT, ❑ �- Method of D" sial <br /> Distance to nearest: Wee' ' Foundation ? - Property Line <br /> LEACHING LINE D No, b Length of lines Q o , 3 7d ' Total iengih/sits �fb <br /> FILTER BED Ci Distance to rest: Weil�• �' Foundation- :2e:::> Property Line d <br /> SEEPAGE PITS I I Depth _ Size r. �1 Number <br /> SUMPS LI Distance to nearest: Well Foundetion> Proparty lire <br /> lSPO5AL PONOS p ��.� <br /> I hereby certify that I have prepared this application and that the work wilt be done iri accordance with San Joaquin county ordinances, state laws, and <br /> rules and regubtiom of the San Joaquin County <br /> Horne owner or bcansad a9m's signature certifies the following: "I ceriity that M the performance of.the work for which this permit is issued, I&hall not <br /> employ any person in such manner as to become subject to.workman'i compensation laws of California." Cohtractor's hiring or subcontracting signature. <br /> certifies the following: "I certify that in the pwtormsnce of the work for%-Rich this permit is'issued, I shah employ persons subject to workman's compensa- <br /> tion laws of lit is 1, <br /> The applica t mu MI f Ah required ins tidRs. Complete drawing on avarse <br /> Q(� Titlb: �rr�'-= fy.e..3�c,1�� <br /> ` S Date: � <br /> EPARTMENT,USE ONLY q <br /> j t <br /> Application Accepted by � � .�AIV�QrJ�w+1 Date 2 - - Area <br /> M k <br /> Pit or Grout Inspection by Date Final Inspection by Date '� <br /> Addttkxel Cornmanis: 'le, /, 's <br /> Applicant - Return all copies to: San Joaquin County Public Health Services i5/l/ arc <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95'241 ��+�� <br /> FEE AMOUNT OUE AMOUNT REMITTED CK CEtYED BY ATE PERMIT'NO. <br /> INFO <br /> EN tba! t V '� f <br />