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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f e 0,,0.gFt <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, 8TOCKTON, CA 95201 6P 4 <br /> (209) 468=3447 <br /> ' (Complete in Triplicate) <br /> ApPILCetion ie hereby made to Sou Joaquin County for a permit to construct and/or install the work herein described. This , <br /> application ie made in c=wliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rulee and Regulations of San" <br /> Joaquin County public Health Services.. <br /> Job Address --.1701 0 Y�� n r /",�'� City .5XdoO� L.t Size/Acreage 1 0 <br /> Address <br /> , .yam' S4 MC7 Phone "�G <br /> Owner's Name / r _ <br /> Contractor <br /> G'l1pSSi: Address_/ " r License No. Phon3Y' <br /> TY—PE WELL/PUMP: NEW WELL WELL REPLACEMENT 171 DESTRUCTION yOut of Service Nell ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR C} OTHER ❑ " Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TASNKZQA'4'4_- SEWER LINES 1Sa DISPOSAL FLD, - PROP. LINE aLP-0 f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS } <br /> -".�-INTENDED USE <br /> TYPE 01= WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 6, O <br /> n IndustrialQ Open Bottom ❑ Manteca Dia. of Well Excavation 1 Dia. of Well Casing-yam <br /> ;Oomesticl Private,- R Gravel Pack C1 Tracy Type of Casing vC Specifications <br /> /� <br /> Cl Public I 1 Other i� © Delta Depth of Grout Seal �� cjO Type of Grout It/A-4`2 <br /> r-I Irrigation ZSR,_ APprosi. Depth D Eastern Surface Saul Installed by it',t C <br /> I <br /> Repair Work Done. U Type of Pump -r c' H,P. State Work Done <br /> Welt Destruction ❑ Well Diameter Se in6 Material 1r Depth , <br /> i Depth k, �"" _-_ Filler Material 6 Depth -6io <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted if public sewer is <br /> �i available within 200 Ieet.1 <br /> r <br /> installation,will serve: Residence r Commercial _ Other <br /> Nu barof living units: Number of bedrooms _ <br /> Character of @oil to a depth of 3 feet: Water table depth <br />- SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> i PKG. TREATMENT PLT, ❑ "" Method of Disposal _ <br /> Distance to nearest: Well Foundation Property Lina <br /> w <br /> LEACHING LINE } ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line -- <br /> SEEPAGE PITS 11 Depth " " Size Number <br /> a.. SUMPS LI Distance'to nearest; Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> E 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: "t comity that in the performance of the work for which this permit is issued,i shall note» <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 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 /> The applicant mus!,sitill for all required inspections. Complete drawing on reverse side. <br /> Signed X Title; Date: <br /> .I <br /> R D TME _ONLY <br /> �� �s 9/ <br /> I Application Accepted by Date m_-+"�..._- Area ._..-..- <br /> "Al Pit or Grout Inspection by Inst Inspoction.by_T Date `�_` e .w <br /> Additional Comments: ! " <br /> Applicant - Return all copies to: SAH 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 <br /> I MOUNT DUE AMOUNT RCASH <br /> EMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> " N f O <br /> . EH 13.24 JAEV,I)n$i <br /> Y EN^�•2e r <br /> 4 <br />