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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> R P999 DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is trade 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 /> Job Address 747 n„r,..�*, City Lot Size/Acreage <br /> _> �i li�t�ir- <br /> Owner's Name John _Ratte Address 2297 Duncan Phone 887-3486 <br /> Conlractor PurvianceDrillers^�� 1.7707 E.Hwy 26 Linde ease N0.377923 Phone887-3554 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT _. DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 09 SYSTEM REPAIR ❑ OTHER 16 t Monitoring Well [7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, Rej uvPAi CIRE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f_1 Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public (-1 other 0 Delta Depth of Grout Sea] Type of Grout Q <br /> Xi trri0ation Approx. Depth ❑ Eastern Surface Soul Installed by Tn' <br /> Repair Work Done U Type of Pump N.P. 40 State Work Done <br /> Wail Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Li REPAIR/ADDITION M DESTRUCTION GI IN septic system permitted if public sewer is <br /> available within 200 Ieet.1 <br /> Installation will serve: Residence_ Commercial^ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, 0 Method of Disposal <br /> Distance to nearest: Well Foundation Properly Line <br /> LEACHING LINE L-I No. & Length of lines Total length/size <br /> FILTER BED 171 Distance to nearest: Well Foundation Properly Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Weil 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 <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Cafifornia,” Contractor's hiring or sub-contracting signature <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 California." <br /> Tha(Ipplicant �,st call Tor i I r 'r inspections. Complete drawing onerse side. <br /> Signed �— Title: <br /> Data: <br /> IV l <br /> FOR PARTMENT USE ONLY a <br /> Application Accepted byD ,�,__ _ r n.. �,Aa.r,6 � Date _1 !1 Area <br /> Pit or Grout Inspection by Date _„f Final Inspection by Date Zq <br /> Additional Comments: ,eF Da— <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES — <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE INF/O//� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /DATE PERMIT'NO. <br /> . EH 19.21 rREV. /NSl /C .�b �J � L [ <br /> CH 11.2! l 1 <br /> 3 7,.,C) `�t <br />