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T 1 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 EMPIRES 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 vork herein described. This <br /> application is rade in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulatione of San <br /> Joaquin County Public Health Services. hh� <br /> Job Address _I� !.` IDEV L,5 City Lot Size/Acreage 4) <br /> Owner's Name S__ZV S Add ess t Phone <br /> ECor ctorll'f�: f�6�' Address✓ t icense No. �� Phone u <br /> ■. <br /> TYPE;JOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well CT <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> 1� . . FOUNDATION" AGRICULT-URE-Wa-[--" '""OTNER-WEL'C'"" ---� PIPITS/SUMPS'�~ -- -- <br /> INTENDED USE'` TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r Cl Industrial. ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> +3; [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> Il Public 1.1 Other fl Delta -Depth of Grout Seal Type of Grout - (� <br /> i Irri�jatian. __ .Approx. Depth I I Eastern Surface Seal Installed by <br /> 'AepaipWork Done ❑ .\Type of Pump. H.P. State Work Done_ <br /> Well`Destruction n,❑ 'Well,Diameter Sealing Material 4 Depth V <br /> ` ' <br /> � Depth <br /> Filler Material i Depth <br /> l �R � _ <br /> TYPE�1OF SEPTIC WORK: NEW INSTALLATION IR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is <br /> } <br /> available within 200 feet:l <br /> �.A --Installation will serve: 3Residence f Commercial_ Other <br /> lip of living units:: Number of bodrS. <br /> ` `ChiEacter,of SON to a depth of 3 feet: � � Water table depth <br /> SEPTIC TANK _❑_.7ypa/Mfq; apacity. No. Compartments .. <br /> PKG.IiI REATMENT.PLT,❑ p/�iC"�` <br /> i . "�` Method of Disposal <br /> x D CFnce to nearest: Well oundation Property Line <br /> ,16� <br /> lEACIINGyLINE` CLfeoeb Length of lines T�ota�tength/size �I <br /> r FILTER BED ❑ Distance to nearest: Weil Foundation �s Property Line <br /> SEEPAGE PITS I I depth '�'a`0 Size 0 1*' NumPer <br /> SUMPS stance to nearest: Well <br /> ugcfation <br /> Fo , � [� P.roperty_iine <br /> l-A � -= <br /> DISPOSAL PONDS ❑ <br /> l hueiay certify that l have prepared this application and that`the.work will be done in accordance with San Joaquin county ordinances, state laws; and <br /> rules ind regulations of the San Joaquin County <br /> Homailowner or licensed agent's signature psriifiei the fdllowing: "I certify that in the performance of the work for which this permit is,issued, I shall not t <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signiture <br /> eartifts the foMowinq;"I certify that in the performance of the work for which this permit is issued, l shailimploy persons subject to workman's compenss- <br /> of Californ <br /> The a'ph st c I for req i ed in ctio s. m e drawing o verse si e. <br /> 11 <br /> Siq Date: <br /> i II <br /> ?FOVDEPARTMENT USE ONLY i <br /> 7fition A cepted by Q Date_ 1 a� Area L <br /> G t Inspection by <br /> DateE Final Inspection by` Data <br /> ! Additional ComnWnts: Q <br /> P nt -�ttgturn 11 copies to: Joaquin County Public Health Services <br /> onmental Health Permit/Services <br /> L4 San Jo a uin P O Box 200P Stk CA 95201 <br /> 7FEE2�'i <br /> INFO AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY PATE PE IT <br /> M -NO. <br /> I EH t4•25 � i l / <br />