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r77 F,; APPLICATION FOR PERIL I T _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES APR O91 ENVIRONMENTAL HEALTH DIVISION �yVIRONMENTAL HEALTH 1601 E. HAZELTON AVE. , 'PHONE (209)468-3 PERMIT/SERVICES P O BOX 2009, STOCKTON, CA 95201 i ` EXP RES 1 YEAR FROM DAT ED (Complete in Triplicate) 3�•—r 5 �I ! Application is hereby made,to San:s Joaquin County for a'permit'to construct and/or install the work herein described. This application is made in compliance[vith San Joaquin County Ordinance No: 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. II City 71C � Lot Size/Acreage Job Address Nif 's Name I�Address 'D� Phone Owner C AkaI Contractor �L `Address` ` License Na. ca L�Phone i •!it7ST_'A FWELL/PUMP:. NEW WELL 0 WELL REPLACEMENT _ DESTRUCTION LI Out of Service Well ❑_ _ �- Monitoring-Well-FET}PUMP INSTALLATION„❑ " _ !SYSTEM REPAlR OTiiER'❑r, !r-^ f , iD[SPOSAI,FL'D:# 4.1 " PROP,,LINE, - "W"_rCE TO:NEARESTi, SEPTIC TANK y f ,SEWER'LlNES% _ FOUNDATION " AGRICULTURE WELL OTHER WELL SPITS/SUMPS INTENDED USE a TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v F] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing m Cl DomesticlPrivate ❑"Gravel Pack ❑ Tracy f� Type of Casing Specifications �QPublic 1.1 Other } °-ten Delta Depth ofiGrout Seal 3o _ Type of Grout I I Irrigation —.Approx. Depth i I Eastern Surface Seal installed by Repair Work Done U Type of Pump Ste► x H.P. „ `-!'14L�1, _ State Work Done Well Destruction ❑ Welt Diameter`�+� rJ Sea ling Material&`Depth f Depth&? , i Filler Material & Depth- 1=%TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I A-DESTRUCTION l I (No septic system permitted it public sewer is available within 200 lost.I Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Wiper table depth-'�-'rte"".. Character of soil to a depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg . °I'" rn Capacity - No. Compartents.- PKG. TREATMENT PLT. ❑ Method,.of:Disp sal' Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines t `` Total length/size y FILTER BED L1Distance to nearest: Weil Foundation Property Line Number ' SEEPAGE PITS t I Depth Sue SUMPS ,_LI_Distance to nearest:, Well_ ,IM -Foundation, Property-Lina- "- - ----- .- _.-- ..- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the kwork will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Countyi I / ! 1I Home owner or licensed agent's signature certifies the,following:.jp certify that.in the performance of the work for which this permit is issued, I shall not employ any pars in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting signature t certifies the toll wi g: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's campensa tion laws [a." `E "" The apo st call for all req ' ed in" ti s. Complete drawing on v side. I ' Signed ' Title: pate: FOR DEPARTN4ENT SE ONLY l ev Area Application Accepted by Data IF i � E Pit or Grout Inspection by /� Date Final inspection by Data Additional Comments: A/ o Applicant - Return all copies to. San Joaquin County Public Health Services, Environiental Health Permit/Services I 1601 E. Raselton Ave., P 0 Box 2009, Stockton, CA 95201 t FEE IfN�f L I— % 4 AMOUNT DUE AMOUNT REMITTED CASH 144A. �RECEIVEp BY ¢=DAT£ PERM(T'NO. EH 13.21(REV.1 95) 3 1- ( EH 14,28 Ll L I