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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION e <br /> P O BOX 2008, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Y R <br /> (Complete in Triplicate) <br /> Application is hereby ma.de,tloSm Joaquwith in <br /> County <br /> noCotutty Ordito nancenNo. 5498and o18628e <br /> and theRules andepegulationsds <br /> of San <br /> application is made 1 otola <br /> Joaquin County Public Health Services. tot Site/Acreage G� <br /> Job Address N, <br /> City /o D <br /> Phone 3 5 F- <br /> A <br /> c,_ <br /> Owner's Name <br /> Address S <br /> Address 14'2--�- �2 License No. ��� Phone <br /> l 3 <br /> Contractor WELL REPLACEMENT C] DESTRUCTION C< Out of geryiee Well ❑ <br /> TYPE OF WELL/PUMP. NEW WELL ❑ ___ O.T.HER.D Monitoring Well C� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 <br /> DISPOSAL FLD, PROP. LINE�� <br /> SEWER LINES PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK --FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL P 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> (] Open Bottom. ❑ Manteca Dia. of Well Excavation <br /> n Industrial f .+ Type of Casing Specifications <br /> U Domestic/Private ❑ Gravel'pack ❑-Tracy Depth of Grout Seal Type of Grout . <br /> I 1'3 Other 0011a1� Public <br /> n Irfioation �.Approx. Depth 0 Eastern,: Surface Seal Installed State Work Done <br /> k Repair Work Done U Type of Pump — H.P. <br /> Sealing Material i Depth 0 <br /> Well Destruction O Well Diameter Filler Material M Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW;INSTALLATION REPAIR.lAQDITtON 1=l DESTRUCTION G aNailabPeiw thin 200 feetstem r�jad it public sewer Is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living unity. Number of bedrooms --' - Water table depth <br /> Character of SON to a depth of 3 feet: LA Z <br /> 9�-� � Capacity / �0-— No. Compartments <br /> SEPTIC TANK ❑ TypelMfg ,_ Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Ez r /p property Lina <br /> Distance to nearest: We Foundation <br /> I r <br /> No. & Len Length of lines '�� r Total length/size 80 r <br /> LEACHING LINE g ' � � dO <br /> FILTER BED Cl Distance to nearest: Well.��� Foundation property Line <br /> YSr Size .` rr Number <br /> SEEPAGE PITS lO Depth r <br /> SUMPS <br /> Ll Distance to nearest: Well Foundation 00" Property Line_Zgte_�­ <br /> DISPOSAL PONDS ❑ <br /> I hereby comity that I have prepared this application and thaw . work will-be-done-in-accordance with San-Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County- -- i <br /> rformance al the work for which this permit is issued, 1 shah not <br /> Home owner or licensed agent's signature certifies the fotlowing "I certify that in the pe <br /> ' employ any person in such manner as to become subject,to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> I certifies the following; "I comity%hot in.the psAormance of the work for which this permit is issued, I shalt employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side'. <br /> /,r Date: ly/ <br /> ti Title: <br /> Signed <br /> T FOR DEPARTMENT USE ONLY <br /> Date _ 9 ` Area <br /> Application Accepted by <br /> . � � Dots <br /> IDt � <br /> or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return 912 copies to' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES s <br /> r ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> r 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 85201 <br /> FEE AMOUNT REMITTED CK RECEIVED BY DATE PERMII'NO. <br /> { INFO AMOUNT DUE CASH <br /> tr,,a.s4IAEV.,.Ns, GC 6d Z�14S m L �I <br /> EK 3�•ffi <br />