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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 jr.. , <br /> PERMIT EXPI RES Y YEAR FROM DATE I SSS <br /> (Complete in Triplicate) <br /> Application is hereby mads to sac Joaquin County for a persalt to construct end/or inatall the work herein deacribed. This <br /> application is akade in CLE licence with San Joaquin County Ordinance No. 549 and 1862 and the Rules and RegulAtione of Sanr�,,,� <br /> Joaquin County Public Health 8ervicea. 1 /�� /�,�j- <br /> Job Address �f � �&11,N ey City� L_ Wt Slze/Acre&3e iC r�" <br /> Owner's Nome Address __-� C <br /> Phpne <br /> CCnlrattw �� dress �Q f^� License No.�,'�� Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl O£STRUCTION Cl Out of Service VeJ2 0 <br /> 2= PUMP 1NSTAiLAT10 ())--SYSTEM REPAIR W JZJJFX � OTHER ❑ Monitoring dell 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES -- �- DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ✓ OTHER WELT PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrrat -- <br /> 0 Open Bottom C3 Manteca Dia, of Well Excavation_ Dia_ of Well Casing <br /> (J Domestic/Private Cr Graves Pack ❑ Tracy Type of Casing-�_/-&+�`-r`- SpecificdtiontZz <br /> i"I Public !� O r fT pelts +�Gapth of Grout Seat �T TYpd of Grout <br /> Irrit)at on Approx. 0 '" I I EasA ,^^5urtac• Soul Instaried by / <br /> Repair Work Done Ix Type of Pump H P � <br /> �tl-'' Stain Work Done <br /> WON D"wiction O YAW Dismatef �� �( Sealing Ilateri.l i Depth <br /> Depth 'Ar�v 111'x+'- Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOtT!ON ,' I DESTRUCTION I ; lNo septic system <br /> permitted it public sewer is <br /> available within 200 feet.l <br /> Installation wiN serve: Residence._._ Commercief_ Other <br /> Number of Wing units, Number of bedrooms <br /> Character of soli to a depth of 3 feel: Water tabid depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments lJ <br /> PKG. TREATMENT PLT. 0 Method of Disposal (� <br /> Oi*WWA to neareat Well_ Foundation Property Line <br /> LEACHING LINE L1 No. 6 Length of lines .� Total length/size <br /> FILTER RED Cl Distance to nearest; Well Foundation _ Propony line <br /> SEEPAGE PITS 11 Depth Size Number_ <br /> SUMPS LI Oimancd to nearest: Well <br /> Foundation ProFerty Lind <br /> DISPOSAL PONOS 0 <br /> I hd+etry certify that I have preparc4 this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, ander <br /> rules and reputations of Ihtl San Joaqui;i County <br /> Horns owner or licensed agent's signeiur• cartitil"the forto'.ving: "t Certify that in rhe performance of the work for which this permit is issued, lshall not <br /> employ any personm <br /> in such anner►,s to becorne sub}ect to workman's compensation IawK of COfrlornia."Contractor's hiring or subcontracting signature <br /> carli4es the following: "I certify that in Use Performsnte 01 the work for which this permit is isaued, I shall employ persons subiect 10 workman's compenu• <br /> tion taws of California." <br /> The sppiica ( or uir <br /> �y q7 tions. Complete drewmg on re er elide. //�� <br /> Signed — J �- <br /> Title; Data: Z <br /> FOR DEPARTMENT USE ONL r- 'CJ <br /> Application Accept.od by /�� <br /> y <br /> ' A�rQe .. � j -�j <br /> Pit or Grout tnapractio _ Date Date Final Inspection�^by 1 y tl Kw c`L Dats _ <br /> AddhioMl Comments <br /> Applicant - Return all copies to: San Joaquin C unty Publicealth Servicee.— <br /> Environtnenta] Health Permit/Servicos <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95'> 1 �(�tq <br /> PR iiM IFEE <br /> AMOUNT DUE AMOUNT REMITTED CK RECEIVED SY LL// L/Lr <br /> CAS PERMl7'NO. <br />