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APPLICATION FOR PER1aIT <br /> SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ERS T EXPIRES 1 YTs <br /> FR 1d D TE S <br /> (Complete in Triplicate) <br /> vork <br /> in <br /> tall th <br /> Application is hereby tsade.to liance rJdOthuSan JoaquinoCounr a ty 0rdirmit tnancenNo. 549struct sand o1862sand the eRules hand eRegulationsdof San <br /> $ <br /> application is made in cel <br /> Joaquin County Public Health Services. �-D�,. Lot Size/Acreage <br /> Y20 City y <br /> Job Address Address <br /> ��� 'L310 <br /> 1 :SOL VKt, Phone <br /> 6z <br /> Owner's Name I J ; <br /> 'S"?13Vr Phane� �7 <br /> i Address Pd � <br /> License No. <br /> Contractor ! a DESTRL1C.. tit of Service Weil ❑ <br /> NEW WELL Q WELL REPLACEMENT OTHER ❑ l 14onitoring Well C7 <br /> -TYPE OF-WELL/PUMP- SYSTEM REPAIR ❑ <br /> PUMP INSTALLATION DISPOSAL FLD. O PROP. LINE a <br /> DISTANCE TO NEAREST: SEPTIC TANK JAI_i SEWER LINES �--- P17SjSLIMPS I <br /> FOUNDATION <br /> AGRICULTURE WELL rte- OTHER WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS Q tl <br /> TYPE OF WELL <br /> INTENDED USE / —�� t Dia. of Well Casi <br /> !] Ope ❑ Manteca Dia. 01 Well Excavation _y--=� <br /> nduatrial <br /> n Bottom Type of Casing_ YL Specifications <br /> yGravel Pack Type of Grout- <br /> 0' <br /> r ut- C <br /> ❑ Tracy f3r� <br /> O0' tic/Priva;e� r Cl pelta Depth of Grout Seal <br /> i'1 PubIIC!,,t' v �l.Osher Surface Seul•Installed by - <br />. .a.�pJ° Approx. Depth 1 I Eastern L,.' -,,"State Work Done - <br /> I I Irrigation r s:, H.P. 3Ve <br /> Repair Work Done ;L7 Type of Pump t Sealing Material i th^ <br /> ,'rte"/-Wellbiametar- <br /> 1 Wa11 Deslrudion Depth f Fillet Dater y�p?Ptlh <br /> L 4 ` <br /> available within 200 lost.- <br /> TYPE OF SEPTIC WORK: NEW INSTALLAT N`I-) REPAIRl�pITION l I :DESTRUCTION l I tNo septic system permitted if public sower +s <br /> r {�I ' Commercial Other <br /> Installation will serve: Residence " <br /> Number of bedrooms <br /> Number of living units: Water table depth <br /> Character of sob to a cl�pth of 3 feet: .. No. Comps <br /> rtments <br /> ❑ Type/Mfg Capacity + p y <br /> SEPTIC TANK Method-of Disposal <br /> PKG. TREATMENT PLT.❑ -dr <br /> ----•-- q�ai�e-t0-nsarest:�----Well--- <br /> ---Foundation••---�� op tY-uQe-��- �. <br /> 7ota1 lengtfi7"size <br /> LEACHING LINE C1 No. b Length of lines Well Foundation .��-� <br /> Property Line <br /> ea } i <br /> r FILTER BED ❑ Distance to nearest: <br /> - - <br /> Size Number { <br /> l SEEPAGE PITS l 1 Depth Foundation, Property Lina <br /> SUMPS l l Distance to nearest: Well <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�ordinancas, state laws, an <br /> rules and regulations of tate San Joaquin County <br /> Hams owner or ficansed agent's signature certifies the following: "I certify that in the performance of the work far which this.permit is issued, 1 signature <br /> shah not <br /> employ any person in s I certify that in the become <br /> s performanceofhe wt to rorkaforswh ch this tpormition �is issued, shall employ persons of California." Contractor's jsubje t to workring 6r tman'scompenss- <br /> certifies the following <br /> tion laws of California." <br /> The applicent must c II for oil required inspections. Complete drawing on reverse side. 3 <br /> Title: a Date: <br /> Signed <br /> DEPARTMENT USE ONLY' <br /> Date Area <br /> Application Accepted by j �¢ Date <br /> Date 7fZ q Final Inspection by <br /> Pk oril rout nspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 K San Joaquin, P O Box 2008, Stkn, CA 95201 <br /> FEE AMOUNT DIME AMOUNT REMITTED <br /> CK RECEIVED BY DATE PERMIT"N0. <br /> � lNF <br /> Etit 11.7e <br />