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11 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95241 <br /> (209) 468-3447 <br /> i� UEDI <br /> Y <br /> (Complete in Triplicate) <br /> in <br /> to <br /> struct <br /> tal <br /> application Application is hereby made;to San Joaquin County for a permit rinancenNo. 549gando18628and the eRules and eRegulations dof Sans <br /> appliaatioo is made in co>xyliance with San Joaquin County <br /> Joaquin County Public Health Services. �y � <br /> I <br /> Ip City ' Lot Size/Acreage <br /> Job Address .- Z Phone 3 344 TS <br /> Address <br /> Owner Name II `14 S-•14.0 <br /> j �� Address 1l�dk � GN License No. <br /> --Phone <br /> Conlraclor s gESTRUCTION Ll Out of 8ervlce Well ❑ <br /> WELL REPLACEMENT n Monitoring Well E7 <br /> TYPE OF WELL/PUMP: 11: NEW WELL SYSTEM REPAIR ❑ OTHER O <br /> PUMP INSTALLATION ( 0 ` PROP. LINE <br /> O' SEWER LINES �b�� —� DISPOSAL FLD.L .�— <br /> DISTANCE TO.NEAREST: SEPTIC TANK n OTHER WELL f_ o �— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATION Dia. of Well Casing <br /> INTENDED USE TYPE OF WELL <br /> ijpan Bottom 0 Manteca Dia, of Weli Excavation rr <br /> C.1 Industrial fype pf Casing Specilications.. -�r — <br /> Domestic/Private ❑ Gravel Pack C] Tracy Type of Grout 9 C K <br /> I.1 Other 0 Delta Depth of Grout Seal <br /> Q� — f i <br /> Publicurface Seal Installed <br /> cl Irrigation �N Approx. Depth d Eastern <br /> H P 1 State Work Done, <br /> Repair Work Done U Typa of Pump Sealing Material & Depth <br /> Well Destruction ❑ Weill Diameter — Filler Material iF Depth <br /> Depth p, <br /> available within 200 feet.) �V <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION fl REPAIRIADDITION ❑ DESTRUCTION LI flVo septic system permitted if public sewer �s \ <br /> k 11 <br /> installation will serve: Residence Commercial____ Other �----- <br /> Number of living units: Number of bedrooms Water table depth <br /> Chafacter of soil to a depth.•of 3 feat: No. Compartments <br /> SEPTIC TANK ❑ :Type/Mfg Capacity_ .--� <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Pro art Line <br /> f Distance to nearest: Welt Foundation p Y. <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of fines Property Line <br /> i FILTER BED ❑ I'Distance to nearest: Well Foundation — <br /> I SEEPAGE PITS I Ill Depth Size Number <br /> 4 <br /> SUMPS LI „ Distance to nearest: Well Foundation Property Line <br /> L DISPOSAL PONDS ©I <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coumy.ordinances, state laws, end <br /> rules and reguiations of the San Joaquin County • •'I certify that in the performance of the work for which this permit is issued, I shalt not (` <br /> Home owner or licensed agent's signature certifies the following, y \\\ <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 chat 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 Californla." .II <br /> The applicant must call for atl required in papions. Complete drawing on reverse side: u_�� <br /> �. SignedIle II Title: Date: 1 <br /> j OR EPARTMENT USE ONLY <br /> _..Date 4 Area _ <br /> Application Accepted by <br /> Olt or Gr�Iction by <br /> Date, Final Ins action by Date }L� <br /> t <br /> Additional Comments. <br /> Applicant - Return &1icopiesto: SAN JOAQUIN COUNTY PUS HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON-, CA 86201 <br /> CK RECEIVED By DATE PERMIVNO. <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED CASH ry <br /> iNPO oe / <br /> EH 13-24 1 <br /> RfV.1i461 \ � 100 q R <br />