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it APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> :i ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> i (209) 468-5447 <br /> IEMIT UPIRES 1-X$A$..r.M..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 /> rippllcation is aade 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 /> it <br /> Job Address 1 I� /�/ City <br /> Lot Size/Acreage <br /> Owner's Name . Address _ Phone <br /> D e2,5 �-o�Ti �S1237- --.`�� <br /> Contractor Address. License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP <br /> �JJNST <br /> ALLATION q— SYSTEM REPAIR OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_l• Industrial ❑ On Bottom ❑ Manteca Dia. of Well Excavation - _ Dia. of Well Casing <br /> i <br /> Ltl-voomestic/Private Cl Gravel Pack Cl Tracy Type of Casing Specifications <br /> M Public C.1 Other C3Delta Depth of Grout Seal Type of Grout <br /> 'l. ¢. <br /> C:I Irrigation —.Arrox, Depth ❑ Eastern 4Surface Seat installed by <br /> Repair Work pone L9�-Type of Pump H.P..._ILZ _ State Work Done <br /> r <br /> Well Destruction O Well Di1amotor � Sealing Material i Depth <br /> P Y <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Of DESTRUCTION CI (No septic system permitted if public sewer , <br /> n available within 200 feet) <br /> Installation will serve: Residence Commercial Other <br /> I4Numbof of living unity. rNumber of bedrooms y <br /> rCharscter o1 $0 ta. depth of 37feet: i <br /> �� a ept ,e Water table depth <br /> SEPTIC TANK, O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O 1 <br /> 13 q Method of Disposal <br /> � ., Distance to nearest: Wells Foundation Property Line j <br /> 14 <br /> LEACHING LINE v � 0 No. & Length of lines Total length/size <br /> FILTER BED Cl Distance td-nearest: Well Foundation Property Line <br /> SEEPAGE PITS IJ Depth Size Number <br /> SUMPS LI Distneeto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 t <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature canities the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> !I employ any peri su manner as to become su t to workman's compensation laws of California." Contractor's hiring or sub-contracting signature `• <br /> I' certifies the fo win I rtif, thatin t <br /> f;l: Y perfor, nc of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- <br /> ition Iewe of allfor la." !I <br /> Th's applic t m t r all r uir n ctt S. C ete-dri nq on re ids. <br /> I <br /> Dole: <br /> Tide: <br /> 5ianed <br /> 11 q FOADEPARTMENT USE ONLY <br /> Application Ace opted by Data <br /> Plt[or Grout Inspection by Date Final Inspection by Dale �-� <br /> Additional Comments: JI <br /> , n _ <br /> Applicant - Return all copiea� to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 85201 <br /> FEE - <br /> INFO AMOUNT Dais AMOUNT REMrTTEO CK CASH RECEIVED BY DATE PERMIT N0. <br /> . EH 13-24 OtEV.1/951 0-0 <br /> EH 114-n, - L r <br />