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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVI�t()NIMAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 j <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> COPY <br /> pMMIT S%P RFS ldR S <br /> (Complete in Triplicate) <br /> Apyliestion is hereby medo to Sm Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ccgaiance with San Joaquin County Ordinance no. 5E9 and 1862 and the Rules and Regulations of Sea <br /> Joaquin cosnmty Public Health Services, <br /> - City .� � Lot Sise Aareege <br /> Job Address <br /> . � _. • `" '_� - Phone -1W �- <br /> Owner's Name d� G ,E�.L Address - SA "" • <br /> Contractor r��O E, nA Address 7 Al &_-44F�r_ f/B License No. '' <br /> 9-�'�-76_Phone <br /> vice Well <br /> TYPE OF WELL/PUMP: NEW WELL ❑ r WELL REPLACEMENT n DESTRUCTION 0 out ofn8toring Well ❑ l <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK l SEWER LINES ______�-- DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT5/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial <br /> (3 Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> I-) Domestic/Private L1 Gravel Pack ❑ Tracy Type of Casing_ <br /> I'1 Public ri Other n Delta Depth of Grout Seal Type of Grout..�� — <br /> I i Irrigation —Approx. Depth l I Eaatem Surface Sall installed by <br /> Repair Work Dorsa U Type of Pump ` H.P. State Work Done <br /> Sealing Material i Depth <br /> Well Desttuction ❑ well Diameter <br /> " a <br /> a Tiller ltaterisl & pepth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I lNo septic system permitted if public"Aa <br /> sow is <br /> available within 200 feel.l <br /> Installation will serve: Residence ✓ Commercial— Other ' } <br /> Number of living units: ... _ Number of bedroom% Y I <br /> Character of soil to a depth of 3 feet: CGA Water table depot <br /> SEPTIC TANK. © Type/Mfg E X Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ ' Method of Disposal <br /> «-r <br /> Distance to nearest: Well Foundation .._ Property Una <br /> LEACHING LINE 0"_No. Ii Length of lines f-^ O ' Total length/sirs <br /> FILTER BED �f 0 Distance to nearest: Welt 4. Foundation Property`Line <br /> SEEPAGE PITS' lrf,, Depth Si.. 4 a Numbir <br /> SUMPS LI Distance to nearest: Welles Foundations ! Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby cartify that I have prepared this application and that the work will be done In acEotdonce with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the Sen Joaquin Cc+mtY <br /> Homs owner or licensed agent's signature certifies the following: "I certify that in the perlormancs of the work for which this permit is issued.1 shad not <br /> employ any person in such manner as to became subject to workman's compensation tawi-of California."Contractor's hiring or sub-contracting signature <br /> certifies the foltowinQ:"I mortify that in the performance of the work for which this pirrnit is issued,I shell employ persons subject to workmen's compensa- <br /> Son laws of California." <br /> 1 The applicant must exit for all required inspections. Comptate drawing on reverse sidi."r } <br /> Signed ` Title: � Date:' - �' �7� z <br /> -FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> 1 Area <br /> PN or Grout Inspection by Oate Final Inspection by Data// <br /> Additional Corn rents: <br /> Applicant - Return all copies to: Ben Joaquin County Public Healtb Services <br /> i Environmental Health Permit/Services <br /> 445 H Baia Joaquin, 0 Boc 2909, Stkh, ITA 95201 <br /> il <br /> EE AtrSOt! T CUE AMQUN RE ITT CK RECEIVEC C E PERhtl7'A10. <br /> FEX 13.2a TREY.fi� 1///c 2ZL <br /> / <br /> EX%4.330 <br />