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1 <br /> APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> X445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> "PERMIT E%PIRES 1 YEAR FROM DATE ISSUED <br /> F (Complete in Triplicate) , <br /> 1 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vor : herein described. This <br /> application.is made in compliance vith.San Joaquin County Ordinance No..,5i+9nd�and 1662 athe Rules and Regulations of San <br /> Joaquin County Publlc-Health Services. = <br /> { % 8 <br /> Job Address �31Y av etA I J& " City /` Lot Slse/Acreage <br /> Owner's Name Address S !'9 Phone <br /> Contractor r r /' �/ Address � License No._ �Phone <br /> TYPE OF WELL/PUMP: hEW WELL--❑~ WELL-REPLACEMENT ❑ ' DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER O Monitoring Well [� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> rFI Public 1-1 Other I1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. -- State Work Done t tJ rte <br /> Well Destruction O{ Well Diameter sealing Material i Depth pss�r J+ <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted il.public sewer is <br /> available within 200 feet.) r <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedroomsF <br /> Character of soil to r depth of 3 feat: - -- - -- - - Watarptible depth <br /> ~� P <br /> t SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartmenta e` <br /> PKG. TREATMENT PLT.❑ Method of D'ga,- i <br /> { Distance to nearest: Well Foundation Property Line cr,Y ( `VJpRQ�/ <br /> / <br /> LEACHING LINE 0 No. III Length of linea _ Total length/size ~r "� •7'S <br /> �,cr W� <br /> FILTER BED G7 Distance to nearest: Well Foundation Property Line �`,(����nS,RR <br /> s J!U%ti <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPSFoundation v Y � <br /> +:+..a��Ul�Disur►ce-to nearest:�..YWell— �- —� Pr <br /> i 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 /> i rules and regulations of the San Joaquin County <br /> ` Home owner or licensed agent's signature certifies the folbwing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> I[ employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hifing or sub-contracting signature <br /> certifies the following:"1 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 /> 4 The applicant must colJor ail r -ed inspections. omplete drawing on reverse side. <br /> Signed X Title: l ik Date: <br /> i FOR DEPARTMENT USE ONLY <br /> Application Accepted by - gY _ _ Date L 0— Area :Z <br /> Pit or Grout Inspection by Date Final Inspection by If A A1 Date -gyp' -- <br /> Additional Comments: <br /> s <br /> Applicant - Return all copies to: San Joaquin County Publ c'Health Services - <br /> Environmental Health Permit/Services <br /> 445 N 3sa Joaquin, P Box 2005, Stko, CA 95201 <br /> INFO AMOUNT DUE I AMOUNT REMITTED K RECEIVED SY DATE PERMIT-NO. <br /> . EH 1 .24 4REV.I it 5 <br /> Ell 14.25 i // <br />