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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONidENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERiIfIT EXPIRES 1 Y FR U DATE ISSUM <br /> (Complete in Triplicate) <br /> work herin describ . Thi <br /> Application is hereby made;to Sen Joaquin Cith San ountquin �Counr a ty Ordirmittnr►ncenRo 549aendnd/o1962satnd thee <br /> eRules andeRegulationsdof Sans <br /> application is made in comp r <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address yyWli_6 <br /> AddressS6� <br /> es !�r - Phone <br /> Owner's Nam <br /> Address ' <br /> Licenie No. <br /> Contractor Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION LJ Out of Service Well <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ .' SYSTEM REPAIR <br /> f I �'u..l SEWER LINES t DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK r a� , <br /> I J` <br /> FOUNDATION ._ - A _RICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE I TYPE OF WELL PFit)BLE •REA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br />{ Cl Industrial J/ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> !!! Type ol.Casing_r Specilications.- <br /> El Domestic!P lvste J 0 Gravel Pack r ❑ Tracy (' ; Type o! Grout <br /> I"l Public 11 Other `[1 Delta .. Depth of Grout Seal , <br /> Irr ation' ^.Approx, Dept 1 I Eastern dace teal Installed by <br /> 'Ak ° State Work Done <br /> Repair Work no U Type of Pump H•P: i <br /> ' J1 " Senting Material & Depth <br /> Well Destruction O Well Diamet4r <br /> R i <br /> ff 1 -» Y -Filler Material i Depth <br /> stn <br /> TYPE OF SEPTIC WORK: NEWANSTALLATION I i REPAIR/ADDITION TaON I I �OESTRUC710N I 1 avaim blerit public sewer is <br /> within 204 feet.) <br /> installation will serve: Residence Commercial •; Other t <br /> Number of living uA'Iit""- -3 Number of bedrooms�� j Na r <br /> { ! d' r t R <br /> Character of soil to a depth of 3 feet: 1 i , <br /> SEPTIC TANK f'"' yP/Mfg C-opacity�_ <br /> PKG. TRF.IATMENT PCT I --�` i <br /> A, <br /> ` <br /> }^ Disrtance to newest: Well Foundation P IR� .r.a <br /> 1 Total ten tli7�iz JOAQUIN GOU[\\'I __ <br /> LEACHING LIMIE ' "CT—Fi`o. 8 Length of lines, ,. i FLl trvl�� <br /> FILTER BE Cl Distancti to ne, st: <br /> Will ' Foundation ��;��q���� i' "L ,, IV1Si0N <br /> t <br /> , { 5 <br /> SEEPAGE PITS I^iDepth Sire `_ { Number '.. <br /> 1 SUMPS- = Ll Dista cb to nssiestWell _ Foundation Property Line --r <br /> J t ' <br /> DISPOSAL PONDS ❑ <br /> I I hereby certify that I have prepared this application and that the work:will be done n accordance with Sin Joaquin county ordinances, state laws, and <br /> rubs and regulations of the San Joaquin_County y <br /> Homs owner or licensed agent's signature certifier the following:"i-c7anify that•iritthe performance of'the work for which this permit is issued, I shall not <br /> signature <br /> employ any perso such manner as to become subject to workman's hick this per maws ss ed,California.@hll ploy ersonsrsubjectring ito workman's compensa <br /> certifies the foko "1 certify that in the performance of the work for which this permit is issued, I ehaH employ pe <br /> tion laws o <br /> The epplic t t call for all r InaplCt . Complete drawing on ve side. <br /> i Signed <br /> Title: Date: y + <br /> R PARTMEN SE ONLY JZ <br /> &�,, AreaAppyton cCc*P1*d"¢yDate l � Date <br /> Pit or Grout Inspection by Date Final inspection by <br /> z <br /> 4(d <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services ; <br /> e Environmental Health Permit/services <br /> + 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 i. <br /> t FEE CK RECEiVEt)BY GATE PERMIT'NO. <br /> { I FO r AMOUNT DUE AMOUNT REMl"ED CASH <br /> 1 <br /> . 7 <br /> EN 13•24 11tEV. /R5 I <br /> t 15A <br /> EN 14.3E // <br />