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iAPPLICATION FOR PERP-3' <br /> SAN JOAQUIN COUNTY PIIBLIC HEALTH SERVICES <br /> ERVIRONIMTAL HEALTH DIVISION ;. . <br /> 1601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> �-' P O BOX 2009, STOCKTON, CA 95201 <br /> F. PSRYIT SSPIRS T YEAR FROM DATE ISSUED ' a <br /> (Complete in Triplicate) ; <br /> Application is parsley mala to Seti Joaquin County for a Permit to construct and/or install the work herein described. This + j <br /> ozglliance with San Joaquin County Ordinance no. 549 and 1862 and the Rules and Regulations of San . <br /> Joaquin County Public/H�eeaalth Services. , <br /> Job Address —1, P '!L/ K City Lot Size/Acreage <br /> Owner's Name ,>Jy Address "Yvm� Phone <br /> Contractor LC/ .tel�.n Address £ License No.7 r--0.! phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES IDISPOSAL FLM. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS <br /> ��. .INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTiON,SPECIFiCAT16NS f ii <br /> . Ll Industrial t O Open Bottom O Manteca Dia. of Well Excavation Dia. of WON Casing <br /> L7 DomesalPrivate ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications <br /> I'1 Public ❑ Other n Delta _ _ D'epthrol Grout Seal . Type of Grout <br /> I I Irrigation ` —Approx. Depth` 1 1 Eastern Surface Soul installed by Ir", <br /> y Repair Work Done '.L7 Type of Pump M.P. I t Slate Work DOM_ <br /> e Well Destruction <br /> ❑ Well Diameter~' sealing Miterlal a Depth <br /> Depth - Filler Materlali'Depth <br /> TYPE OF SEPTIC WORK: ,.NEW INSTALLATION 1 I REPAIR/ADDITION' .IT DESTRUCTION 1:1 (No septic system permitted if public sewer is <br /> ' �� •available within 200 feet I <br /> Installation will terve: Residence_ Commercial_ Others <br /> *4�w Number of living units:_ Number of bedrooms <br /> Character Of sea to a depth of 3 fast: All T. ; _ - <br /> SEPTIC TANK. O Type/Mfg r Water table depth <br /> PKG. TREATMENT PLT.❑ <br /> CepaaitV ' � m <br /> No. Compartents <br /> . s.. <br /> Method of Diapoaal <br /> Distance to nearest: I Wali Foundation Property Line <br /> LEACHING UNE , ❑ No. b Length of lines f 1 .7otal length/size <br /> FILTER SED ❑ Distance to nearest: aU Well f %�+ dl r^ <br /> Foundation y�_ property Line ^ <br /> SEEPAGE PITS I I Depth Size .Number <br /> SUMPS + ❑ Disiartce to nearest; Well '� Foundation i <br /> DISPOSAL PONDS 4 ❑ ,/r' Property Lute <br /> I hereby'cenity that I have prepared this application and that ih'e work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County - <br /> Home owner or licensed agent's signature certifies the fokowinp; "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 ss to become subject to workman's compensation laws of California."Contractofs hiring or wbcontracting signature <br /> cenila the following:'•1 unity IMt in the performance of ths'work for which this permit is issued, I shall emdoy persona subject to workman's eompensa- <br /> tion lawn o/California.,,fomb i -._ <br /> The applicant must yelffor 11 ragt�r\ p fp , Complete drawing on reverse side. <br /> Signed x f/ \r'.. / iib:--- _Date: <br /> ;FOR DEPARTMENT USE ONLY <br /> Zon Accepted by - • Date r <br /> _ Arw <br /> r GrWt Impaction by_t �ne... Finel Inapeceon bV ate r 1 / <br /> Additional Comments: <br /> Applicant - Return all copies-'to:_San Joezlnin County Public ifeelth <br /> Services. Environmental Health Perait/Services <br /> 1601 H. Hatelton Ave., P 0 Box 2009, Stockton, CA 95201 ..� <br /> INFO AMOUNT DtlE AMOUNT REMITTED CK RECEIVED BY DATE PERMRNO:. 1 <br /> • ER 1em1eEV.,rx 51 <br /> i <br />