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r <br /> APPLICATION FOR PERMIT # <br /> c SAN JOAQUIN COUNTY PUBLIC HEALTH SSRVICE;S b <br /> ? " <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 2 ' �• ' <br /> (209) 468-3447 1990 ; <br /> YEAR k IRONMENTAS. �4 A1..Ti l <br /> (Complete in Triplicate) PERM IT/ISERVICES <br /> Application is hereby mede,to San Joaquin County for a permit to construct and/or install the work herein described. This n <br /> application is made-in cowliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> -Joaquin County Public Health Services. <br /> rt l <br /> Job Address X3321 - __ City Lot Size/Acreage E <br /> Owner's Name Address Phone <br /> Contractor AddressOLicense No. 2 Phone <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION 0 Out of Service well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR , OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK4 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION; AGRiCUL7UifE 1NELIr OTHER WELL PITSlSUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> VR omestiO Private 0 Gravel Pack . 0 Tracy Type of Casing '�' - Specifications <br /> M Public" f:7 Other ❑ Delta Depth of Grout Seal 4 Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern d Surfaee Seal Installed by <br /> Repair Work Done }Type of Pump ..44,A J4!z— H.P. I' State Work Done <br /> Well Destruction Wall Diameter Sealing Material h Depth <br /> Depth f Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION L'f DESTRUCTION 0 1No septic system permitted if public sewer is <br /> available within 200 fast.) <br /> Installation will serve: Residence _.. Commercial Other <br /> Number of living units:t Number of bedrooms <br /> Character of$oil to a depth of'3 feet: t Water table depth <br /> SEPTiC TANK ❑ Type/Mfg ! Capacity No. Compartments <br /> PKG. TREATMENT PLT.G7 �"` -`'� Method of Disposal <br /> ' Distance to nearest: Well Foundation Property Line <br /> 4 <br /> -.,.... <br /> LEACHING LINE Ul.�Na. 8 Length of lines Total"Total length/siz`e <br /> FILTER BED CI Distance to nearest: Well Foundation Property Line <br /> 3 -t <br /> k <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS .LI.. -Distance to nearest: Well Foundation. Property-Line•— <br /> DISPOSAL PONDS 4 0_, <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 /> rules and regulations of the San Joaquin County <br /> Homeowner or.licensed agent's signature cenifies the following; 'V certify that in the performance of the work for which this permit is issued, I shall not <br /> empioy 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: 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 /> The applicant r all required Ops coons, Complete drawing on reverse side. <br /> Signed -Title: ..,_ ��.�r -- Date: <br /> 9 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by " Date I Area <br /> Pit or Grout Inspection by 1 Date Final Inspection by 4Data �� 1 <br /> Additional Comments: <br /> F <br /> Applicant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> .ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON., CA 9$201 <br /> t <br /> IEEEO <br /> aAIMOUNT DUE AMOUNT f wirrEO GASH,s �RECEIVED By DATE PERMIT'NO. <br /> . IH 13-241REY.des) 7�at2].J Rb —31�• <br /> EH 14.26 <br /> } <br /> i <br />