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I APPLICATION',FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN. PHONE (209)468-3420 <br /> w <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 1. <br /> ERMI T._1 I RES 1-YEAR FROM DATE I SSFM <br /> (Complete in Triplicate) <br /> f <br /> Application is hereby made•to San.Joaquin County for a permit to construct and/or install the work herein described. This <br /> application In made in compliance with San Joaquin County Ordinance No. 549 and 1.862 and the Rules and Regulations of San <br /> 4 Joaquin County Public Health Services. <br /> Job Address;_'.J ="� A%' T S��C 1 f- <br /> City Lot Size/Acreage <br /> �7 �j <br /> Owner's Name GA- V[�� Address ---, ~ G _.__ / 7 7-r/ <br /> f. _ Phone <br /> ,41 <br /> j Contracto C- � <br /> -6Q S Addressr 5 7� License No.37 Vr _Phone'33 V'Y7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALI_ATION�- n SYSTEM REPAIR ❑ OTHER 0 monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINER <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ' INTENDED USE_ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation1- Dia. of Weil Caairig <br /> �omasticIPrivate Gravel Pack 'E3 Tracy Type of Casing-_��� Specifications <br /> F) Public f:7 Olher'.w Fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation 't-Ga Approx.'Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump • ^`- H.P. Z <br /> State Work Done <br /> Well Destruction O„/Wali Diameter Sealing Material e Depth , <br /> Depth 4illor Material R Depth G� <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I l REPAIWADDITtON I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> ! available within 200 feet.) <br /> Installation will soave: Residenoe� Commercial_ 'Other � <br /> Number of living units: "Number of bedrooms <br /> Character of$00 to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mf <br /> '= ` Capacity No. Compartments <br /> PKG. TREATfuIENT PLT.❑ Method of Disposal Y" <br /> h Distance to nesrest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Toisi"leng[h/size <br /> FILTER BED !, 0 Distance to nearest: Well Foundation, L Property Line <br /> SEEPAGE PITS I I ' Depth -L-size <br /> Number <br /> SUMPS ; CI, Distance to nearest: Well Foundation Property-Line <br /> DISPOSAL PONDS CIi <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 /> Home owner or licensedlagent's signature certifies the following: 'V certify that in the performance of the work for which this permit is isI shelf not <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 ft,following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." k <br /> The apO ant must I for all required inspections. Complete drawing on reverse side. <br /> Signed Title: ti E Date: <br /> RTMENT USE ONLY <br /> Application Aeetipted by Date Area �72 <br /> r <br /> Inspection b <br /> Pit or r In � y pate �D Final Inspection by Date � �3 <br /> Additional Comments: <br /> Applicanti- Return all copies to: San Joaquin County Pub is Health Services a <br /> I Environmental Health permit/Services <br /> w i 445 N San Joaquin, P O Box-2009, Stka, CA 95201 <br /> FEE AMOUNT DUE ` AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> INFO H <br /> • Ex 1}24[HEV:i/R sr r�� / <br /> EH 14.1!! !J f . <br /> 4R <br />