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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Q. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> I�I <br /> (Complete in Triplicate) , <br /> Application its hereby made to Sao Joaquin County for a permit to construct and/or instaU the work herein described: This <br /> I with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> application is made in compliance <br /> Joaquin County Public Health Services. <br /> t <br /> Rd <br /> StoCKton Lot Size/Acreage <br /> Job Address <br /> '_3:2211�2�:E�:'�E =`fit ':T"f •1e . Cit <br /> 9615 E.' Waterloo Rd. StocKt�gna <br /> Owner's Name Dari DYU11i3YC1. Address , <br /> Purviance Dril fere P. Q. Box 54,Lirrdgr ense No. 377923 phone <br /> 887-355 <br /> Contractor� <br /> WELL REPLACEMENT 0 DESTRUCTION C7 Out of Service Well Cl <br /> TYPE OF WELL/PUMP: NEW WELL I� - OTHER Q Monitoring Well <br /> PUMP INSTALLATION ]Si o- SYSTEM REPAIR ❑ <br /> DISPOSAL FLD, <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �-- <br /> PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 16'+ <br /> —----- Dia. o} Well Casing <br /> f� Industrial Open Bottom [� Manteca Dia, of Well Excavation <br /> Type of Casing Steel Specifications <br /> Domestic/Private Cl Gravel Pa`lck Tracy 50 r Type of Grout <br /> Public <br /> L C 0 7 Other i D Datta Depth of Grout Seal <br /> Dil IrriOatian 60D Appro IIIx. Depth 0 Eastern Surface Saul Installed by <br /> Repair Work Done U Type of Pump tU_rb H.p. 75 State Work Done <br /> Sealing Material i Depth �+ <br /> Well Destruction O Well Diameter Q1 <br /> i Depth Filler:Material 4 Depth f" <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1=1 DESTRUCTION G availablle'within 200 feetsystem it,ed it public sewer is <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. 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, C1 I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED [-I Distance to nearest: Well Foundation Property Line <br /> IM <br /> SEEPAGE PITS I I Depth IM Sire Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Lina <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 Ito become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." 11 <br /> The pplicant m t tali for II qui ` inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Corp. SecretaryDate: 5/7Z91 <br /> FOR DEPARTMENT USE ONLY <br /> Date b Area <br /> Application Accepted by / <br /> DDettl� <br /> Pit or Grout Inspection by ` Date r final inspection by <br /> Additional Comments: I" <br /> it <br /> Applicant ^ Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIdENTAL HEALTH DIVISION PERI[IT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DtIE AMOUNT REWTTEO CK RECEIVED By DATE PERMIT NO. <br /> INFO CASH <br /> . E�t$•t�IriEy.iiHsl � <br /> Eft <br /> F II <br />