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APPLICATION FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STMKTON, CA 95201 <br /> (209) 468-3447 <br /> IRBES Y <br /> (Complete irk Triplicate),` <br /> Application is hereby made to San Joaquin County for s permit to construct and/or install the vork herein described. This <br /> application ty Pude in Health <br /> se v with San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> i <br /> Joaquin County Public Health Services. <br /> Job Address q <br /> City r4 Lot Size/Acreage <br /> Owner's Name 41 A 1�-n--�!z-- L Address 1. Phone —7;"A <br /> Contractor Addr <br /> TYPE OF WELL/PUMP: v ___ License No.a '3� _ Phone ,� 77 <br /> NEW W L WELL REPEACrMENTTn_ ' - DESTRUCTION_❑-put-or-•Servlce-We-1:1_0 • <br /> PUMP INSTALLATI SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST; SEPTIC TANK -Z� SEWER LINES . L7 <br /> ------ DISPOSAL FLp,6=&:2_ PROP. LINE�d <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n ustrui , Open Bottom ❑ Manteca Dia. of Well Excavation <br /> D eaticlPrivate Cl Gravel Pack / Dia. of Well Casing <br /> ❑ Tracy Type df-Ca-sing Specifications <br /> ublic I�1 Quer 0 Delta Depth of Grout Seal r <br /> M Irrigation 30 q r, Type f Grou <br /> .. pprox. Dept n Eastern Surface Soul Installod by �� <br /> Repair Work Done U Type of Pum °yr <br /> 4�.:. H.P. State Work Done_ <br /> Wali Destruction ❑ Well Diameter _ Sealing Material &-Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR IA•0017ION 1«1, DE57RUClT10N GI {No septic system permitted if public sewer is <br /> Installation will serve: Residenes .r Commercial available-within_200-fest.l <br /> Other <br /> Number of living units: Number of bedrooms oe <br /> Character of soil to a depth of 3 feet: % �1l <br /> SEPTIC TANK. © Type/Mfg tom,Water table depth i Capacity : _ .' ! <br /> PKG. TREATMENT PLT, G3 No. Compartments <br /> Distance to nearest: Well Foundation .�. — <br /> Method of Disposal <br /> _ ropenyf <br /> PLine <br /> LEACHING LINE ❑ No. & Length of lines <br /> 1 FILTER BED -Total length/size' <br /> Distance to nearest: Well ''i <br /> y _-__ Foundation <br /> Property Line . <br /> {SEEPAGE PITS '�� <br /> I1 Depth Size <br /> Number <br /> SUMPS <br /> LI Distance to nearest: Well Foundation <br /> ,DISPOSAL PONDS ❑ _ Property fine ` <br /> I hereby certify that I hav <br /> rules and e prepared this application and that'the,woik will be done in accordance with San Joaquin county ordinances, state Paws, and <br /> regulations of the San Joaquin County <br /> IHome 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 sub-contracting signature <br /> certifies the following; "I certify that in the performance of the work for which this Permit is issued, I shall sm to <br /> tion laws of Californla." P Y Persons subject to workman's compensa• <br /> ,i-The-a <br /> pplicant-must-caU-}or aH-required-inspectigta6"^Complste-drawing on'reverse sills'^"" �• �-'- --^�--�----...-c=_-�---.-.--�.-.�.�� <br /> { <br /> Signe -f Tide: <br /> Date: 9 <br /> TMENT USE ONLY <br /> Application Accepted by �l ` <br /> Data 1. Area <br /> Pit rou apection <br /> Data ZL-L' Final Inspection byr / <br /> PD <br /> ate1 <br /> Additional Comments: <br /> Appiicf►at=ReturnA all aopiee'-to: ggN JpAq YN COUN YT PUBLIC HEALTH SBRVCBS <br /> I <br /> ENVIRONMENTAL-HEALTH DI <br /> VISI`ON PERM <br /> IT/SERVICES <br /> 945 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> EFEE AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT.NO. <br /> HI`'�rnl:V.s `� 1 —074 � <br />