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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 r <br /> (209) -468-3447 <br /> - SAR PEN <br /> Y <br /> (Complete in Triplicate) a <br /> Application is hereby !pada to Spa Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in calth anceSe.ry withces. San Joaquin County Or inance No.. 549 and 1662 and4.the Rules and Regulations of San <br /> Joaquin County Public Health Services. . /f <br /> Job Address r L{/ / •L <br /> Cit <br /> Y ot Size/Acreage d <br /> Owner's Name 973 ' <br /> f} Address Phone 5v,/— <br /> Contractr1y r►t P ,► <br /> Address Lir1C_o)� License No.5.30(0?2-- <br /> TYPE OF WELL/PUMP: Phone `��-�`� <br /> NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR L) OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ❑ <br /> - DISPOSAL FLO. PROP. LINE 3- ,R <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial IFOOpen Bottom ❑ Manteca t r t/ <br /> ��' �� Dia. of Well Excavation Dia. of Well Casing <br /> A L?V-O—testic/Private b Gravel Pack ❑ Tracy T <br /> M Public Type of Casing Specifications--Z <br /> ..yyCl 0 her i❑ Delta Depth of Grout Seal <br />` CJ Irrigation Q A Type of Grout text tTf�` <br /> pprox. Depth ❑ East�ern Surface Seal Institled-rb <br /> Repair Work Done 0 Type of Pump _. S LL 0..4 <br /> �"�'- <br /> Well Destruction p Welt Diameter 8'r Sealing !Material i Depth State Work Dons-- <br /> Depth F111er Material-& Depth i <br /> TYPE OF 5EPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION ❑ DESTRUCTION CI 1No septic system permitted if public sewer is <br /> Installation wilt serve: .. Residence { available within 200 Joel,} <br /> Commercial Other ' <br /> Number of living unite Number of bedrooms <br /> Character of soil to a depth of 3 feet: — <br /> SEPTIC TANKD Type/Mfg Water table depth <br /> `- Capacity _ <br /> PKG. TREATMENT PLT, C7 No. Compartments � <br /> r i Method of Disposal <br /> Distance to nearest: Well. Foundation <br /> Property Lina <br /> LEACHING LINE Cl No. 6 Length of lines i ! <br /> FILTER BEDTotal length/sire <br /> f:1 Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS 11 Depth <br /> Si:e <br /> SUMPS Number <br /> LI Distance to nearest: Welf # <br /> DISPOSAL PONDS ❑ Foundation Property Line <br /> I hereby canify that I have prepared this application and that the work wilt be done in accordance with San Joaquin County ordinances, state laws, and <br /> rules and regulations of the San Joaquin County I <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 10 workman's compensation laws of California." Contractor's hiring or sub-contracting signature r <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 law*of California." <br /> The applicant must call for al quired inspgctions. Complete drawing on reverse fide. <br /> Signed X_ <br /> Title: s / <br /> Date: C7 <br /> FO EPARTMENT USE ONLY <br /> Application Accepted bye �^ Z <br /> Date Area <br /> Pit o Grau Inspection by 27 <br /> Date Final Inspection by <br /> Date Q <br /> Additional Comments: <br /> is .L✓>` <br /> Applicant - Return all copies to: JOAQUIN COUNTY PUBLIC HEALTH SERVICES /fl <br /> j - <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES - - S" ^ <br /> 445 N SAN JOAQUIN, p 0 BOX 2009, STOCKTON, CA 95201 '? <br /> FEE AMOUNT DUE CK - <br /> INFO , AMOUNT REMiTTFO CASH FiECEfVEO 8Y DATE <br /> .? F1AMIT NO. <br /> N � , <br />+ EM 13-74 1AEV,I/ngr - <br />