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r APPLICATION FOR PERMIT <br /> SANIJOAQUIN 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 YE4AH FROG 'DTSS <br /> (Complete in Triplicate) <br /> Application is hereby made to San Josquiareounty for a permit to construct and/or install the work herein-described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health ServicesLL;g, <br /> ! <br /> City Lot Size/Acreage <br /> Job Address <br /> ` dress � � - Phone ; <br /> Owner's Name ^., _ _ <br /> K� * 9"a� IV � L�� Phon � <br /> Contrac � Addres Icense <br /> TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT DESTRUCTION ❑ Out of Service well ❑ i <br /> Monitoring Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ 1 <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> �^ PROP. LINE <br /> -.- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } <br /> INTENDED USE 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Din. of Well Casing <br /> C7 Indu _,I„❑ Open Bottom 1 �•CD Manteca '-Dia. of Well Excavation <br /> ;., ,f T %_ of Casing <br /> _ Specifications. <br /> omestielPiii7ata�""��C1-Gravel-Pack, ❑ Tracy .yip _ g Type of Grout <br /> f"! Public " i"1 Other n Delta depth of Grout Seal A, <br /> I i Irrigation f �Approx.`Depth I I Eastern /+ SurState Work Done <br /> face Seal Installed by }Wv <br /> Repair Work Done JLeTypa of Pump H.P. � `Sealing Material A Depth <br /> w <br /> Well Destruction ' ❑ 'Well Diameter ]Filler Material i Depth <br /> Depth f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ 1 REPAIRIADDITION I I` DESTRUCTION I I Mo septic system permitted it public",. is <br /> A available within 2011 feet.) <br /> Installation will serve: Residence,... Commercial Other <br /> Number of living units: Number of bedroomsY <br /> ; Character of ROM to a depth of 3 feet: Water table <br /> , <br /> .. depth <br /> ❑ TYPe/Mf - s - -S <br /> SEPTIC TANKCapacity_ ' Na. CAAithg <br /> PKG. TREATMENT PLT.0 t <br /> Math",!"}gr <br /> `1 <br /> 1t L Distance to nearest: Well Foundation Prtrty Lint ��VV// <br /> Total lengthlsi h <br /> LEACHING LINE h ay�0 No. 6i Length of lines '- <br /> IVI <br /> R EALTM-SE <br /> 7VIC S <br /> FILTER BEO [a Distance to nearestWell Foundation ENI DNMENTp .MLK DIVISION- <br /> SEEPAGE <br /> 1Vk iONSEEPAGE <br /> 1 <br /> PITS' ` I I Depth Size Number <br /> r SUMPS, "_#,,,.,„d_ L1 TM_Distance to ""rest:, Well Foundation Property Line <br /> DISPOSAL PONDS ❑ } <br /> I hefeby cenify 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■gent's signature certifies the following: "I cavity that in the performance of the work for which this permit is issued, 1 shall not <br /> i employ any parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> b <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 Californls." f <br /> a <br /> kThe applicant an required insEect s. Complete drawing on re side. <br /> Signed X Title: . Dater <br /> FOR DEPARTMENT USE ONLY �,r <br /> Application Accepted by Dots Area <br /> Pit or Grout Inspection by Date Final Inspection by dc Date"_�T_ <br /> Additional Comments: <br /> Applicant - Return all copies to:- San Joaquin-County public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REM&ED­_ Ct( RECEIVED BY I DATE PERMET NO. <br /> INFO <br /> ♦ EFS,3.24 IREV.1/RS, <br /> EH t476 . <br />