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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> R <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. 5119 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> e ` 2 / S City Lo k f Lot Size/Acreage <br /> Job Address <br /> E� Address a Phone <br /> Owner's Name <br /> �, nta-'s srcc . 7o2(e Tu ( d � � - Rap <br /> Contractor�- Address <br /> `fJ k)_c% nee ffo 'Phone <br /> TYPE OF WELLIPUMP: NEW WELL CI SYSTEM <br /> REPLACEMENT n DESTRUCTION L1 Out of Service Well ❑ <br /> i <br /> SYSTEM REPAIR f� OTHER ❑ Monitoring Well [7 <br /> PUMP INSTALLATION ❑ <br /> iSEWER LINES � D15POSAL FLD. PROP. LINT: <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION ._ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> in industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation <br /> Type of Casing Specifications <br /> U Domestic/Private ❑ Gravel Peck L7 Tracy Type of Grout ;^• <br /> M Public (-I Other 0 Delta Depth of Grout Seal <br /> G IrrigationbNtiC' Approx. Depth � ❑ Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump sv�f�in+ H,P• State Work Done <br /> Well Destruction O Wel! Diameter <br /> Sealing Mfateri�Vptb N <br /> Depth Filler Material i Depth <br /> stem permi <br /> TYPE of SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION M DESTRUCTION CI arvailable'w thin 200 feet+)ad if public sewer is <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 r <br /> Y Capacity Na. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> Method of Disposal. r <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size (� <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line - <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 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 sub-contracting signature <br /> certifies the following: "I certify that in the pefiormance 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 applicankmu sll for all r fired in"plions. Complete drawing on reverse side. L--3 (:: _ / <br /> Signed X_ �Title: awmeDate: <br /> R ARTMENT USE ONLY <br /> Application Accepted by litf� Date <br /> 1- Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date 3 ° <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES , <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 85201 <br /> FEEKAMO,IJ2! AMOUNT REMITTED ECASH <br /> RECEIVfD BY GATE PERMIT'N0. <br /> INFO [ qEM 13.24 IREv.ii e v �I ! f ! 0 V <br /> M.626 <br />