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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL -HEALTH DIVISION <br /> t ' P O BOX 2009, STOCKTON, CA 95201 <br /> f <br /> (209) 468-3447 <br /> I" (Complete in Triplicate) <br /> struct ork <br /> in <br /> Application is hereby srtads.liance withuSanCJoaquinfor <br /> countyrdinancenMo. 549Band,le62 and thend/or install eed <br /> Rules andRegulationsof Sana � <br /> CcM <br /> application ie made n <br /> Joaquin County Public Health Services. <br /> 23435 E J ST. RT. 1 2. '" City m <br /> Cleents Lot Size/Acreage <br /> Job Address <br /> ( 209 )982-5629 <br /> Owner's Name <br /> Brian rin Colburn Address 413 To Stewart Lathr.0 _ Phone <br /> Purviance Drillers, Inc- 377923 Phone887-3554 . <br /> Conttaclor--- _ <br /> Address 17707 E- Hw 26 Linc3L�crAnse No. , <br /> TYPE OF WELL LIMP: ;; NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well <br /> . OTHER O Monitoring Well <br /> PUMP INSTALLATION � SYSTEM REPAIR C7 <br /> DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> / L� Industrial )Q Open Bottom D Manteca Dia. of Well Excavation��---- Specifications.- - - — <br /> Type of Casing C t-P P 1— <br /> U DomeaticlPrivat L1 Gravel Pack ❑ Tracy 05 ' Type of Grout cement <br /> �l Public . <br /> !'1 Other ❑ Delta Depth of Grout Seal --- <br /> CM Irrigation 2.1.Approx. Depth El Eastern Surface Seal Installed by f <br /> H P State Work Done- <br /> _� <br /> Repok Work Done L3 'type of Pump Sealing Material k_Depth <br /> '"'Well Destruction O Well Diameter <br /> F Depth Filler Material i Depth <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ID REPAIN/ADDITION C7 DESTRUCTION CI-aNailabPe�within 200 feetr jed if public sower is <br /> Installation,w4l servs: Residence Commercial— Other <br /> -Number of living units: Number of bedrooms water table depth <br /> Character of aoilJto11 a depth of 3 feet: No. Compartments <br /> . SEPTIC TANK t ❑ iiTyps/Mfg Capacity <br /> Method of Disposal <br /> PKG, TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation. Property Lin®` <br /> y <br /> I Total length/size <br /> LEACHING LINE ❑ ii No. 8 Length of lines - <br /> FILTER BED ❑ ;I Distance to nearest: Well Foundation properly Lina <br /> ' <br /> W. Number <br /> SEEPAGE PITS ( I :':Depth Size <br /> (( SUMPS <br /> Irl `I Distance to nearost: Well Foundation Property Line. <br /> I DISPOSAL PONDS ❑ .� <br /> I hereby certify lhat,l haus prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stat a laws, and ; <br /> rules and regulations.of the San Joaquin County <br /> ,r Home owner or licensed agent's signature certifies the-following: "I certify that in the performance of the work for which this permit issued, I shall not <br /> f employ any person in such manner as to become subject to workman' California,"s compensation laws of Californa• Contractor's hiring or sub contracting si pansa- <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 comen <br /> tion laws of California." :r <br /> Th p rcan- st call for 11 u inspections. Complete drawing on r grse side. <br /> Signs <br /> Title: <br /> Date: <br /> r F DEPARTMENT Dat Area <br /> USE ONLY <br /> l tit <br /> Application Accepted by - pate• <br /> Pit or ro Inspection by� Date LCL--L- Final Inspection by <br /> r � _ <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, STUCKTON, CA 98201 <br /> FEE CK RECEIVED By DATE PERMIT NO. <br /> INFO` AMOUNT DUE AMOUNT REMITTED CASH ^� <br /> €H 13-2 IREV.1"n sl <br /> EH^,4•m <br /> S <br />