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APPLICATION FOR PERMIT <br /> / SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> D yf" ENVIRONMENTAL HEALTH DIVISION <br /> n ` P O BOX 2009, STOCKTON, CA 95201 <br /> Lj (209) 468-3447 <br /> j)EIR1`TT FxpIRES 1„�EAR FROM DATE ISSUSQ <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. /O <br /> / O7l C �CANJ-0 +van - City ACJ4A9/�'y Lot Size/Acreage <br /> Job Address <br /> Owner's Name /1 <br /> G. °�A[lDET Address � � �• Ae-,w A � Phone <br /> ��� p r` <br /> Contractor.,�_��`PM�Address � � Ei r7�71�� License No. s��_Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1 7 Out of Service Well O <br /> Monitoring Well �I <br /> SYSTEM REPAIR ❑ OTHER O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS « <br /> M Industrial O Open Bottom O Manteca -Dia. of Well Excavation. 1 Dia. of Well Casing <br /> U Domestic/Private -Type of Casing PVC Specifications Grovel Pack O Tracy �n a Type of Grout gMdrC& 6 <br /> M Public CI Other O DeltaVif <br /> -Depth of Grout Seal AS6 /s �. iNG <br /> Irrigation =Approx. Depth D Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION Cl (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line Q <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS if Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS D <br /> 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: "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 to workman's compensation laws of California." Contractor's hiring or subcontracting signature <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 laws of California," <br /> The opplicaff7ftstcall for all required iy n�ctions. omplete drawing on r se e: / C} <br /> Signed Title: �GZ'� Date: <br /> FOR,DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 2-13"' <br /> Pit or Grout Inspection b DateFinal Inspection Date /17L.L_(—� <br /> G G 3 -- _ <br /> Additional Comments: er' e0 <br /> Applicant - Return all copse to' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH K I RECEIVED BY DATE PERMIT'N0. <br /> INFO ^^ l Q <br /> . EH 13.24IREV.iin5) N.V <br /> EH 11.26 <br />