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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 /> _UAR PROM DATE ISAWW <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 coe�iliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Add37--9 <br /> rsaa _ City 'Lot Size/Acreage Z <br /> Owner's Name TROU47 /�/ Address '�.�i�/ Phone <br /> t /�' ✓ <br /> Contra[tor S `7 Address �l� /LIQ License No. "/[oS Phone7�` <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L1 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitooriiyng We <br /> - ll U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES `r_ DISPOSAL FLO. — PROP. LINE :L6 � <br /> FOUNDATION-- AGRICULTURE WEILOTHER WELL4-, PITS/SUMPSQ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> 0 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ArGravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1-1 Otper Q Delta Depth of Grout Seal Ty o Grout ! <br /> CJ Irrigation �,-OApprox. Depth D Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P, Stare Work Done_ <br /> Well Destruction ❑ Well Diameter sealing Material <br /> ..& Depth <br /> Depth Filler Material i Depth ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION M DESTRUCTION G (No septic system permitted if public sewer is <br /> available'Within 200 feet.) <br /> Installation wilt 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 ❑ Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal ---� <br /> Distance to nearest: Well Foundation Property Line y <br /> LEACHING LINE Ef- No. & Length of lines <br /> g Total length/size � <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size ` 1 7ber <br /> SUMPS Li Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 4 <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 Iaws,•and <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the Performance o,the work for which this permit is issued, I shall net <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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantust requir i s, Complete drawing on raver side. <br /> Signed <br /> la: <br /> 11% Date: <br /> FOR DEPARTMENT USE ONLY <br /> i <br /> Applic Accepted by �-- Z'� I <br /> Date Area <br /> C1 <br /> Pi ar Grou Inspection by Date�� Y�7� Final Inspection by ' ` M pale Lc) <br /> Ad r onel Comments: `h <br /> Applicant - Return all copies to: SAN JOAQUT�N� COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL <br /> i <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O,SOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DOE <br /> INFAMOUNT REMITTED CK <br /> O CASH RECEIVED BY DATE PERMIT'NO. <br /> go <br /> + EH l3.24 IREV.i i n 51 �^ /Z <br /> EH;�•I6 t Q C7 �/ FO <br />