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Se�1 4�1► �6 APPLICATION FOR PERM I T <br /> r �g�ra/"i Ups � - <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> 0 _3;?_ ,ry-- ENVIRONMENTAL HEALTH DIVISION <br /> 3;L t P O BOX 2009., STOCKTON, CA 95201 <br /> 4x 17 ci (209) 468--3447 <br /> 'i7- 7 b A rw s <br /> 97 - 00 (Complete in Triplicate) <br /> it p -2-PS B!N c <br /> Application is htr6by made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance Nsa, 5} d 1862 and the Rules and Regulations of flan <br /> Joaquin County Public Health S vices Y�? <br /> g �` <br /> Job Address City Lot Size/Acreage <br /> 9 <br /> f Owner's Nome_ n ` o <br /> /V l/Address Q� Phone <br /> r113AfX h q3 2_ -gs17 <br /> Contractor Address a No Phone <br /> TYPE §4M1*%&--WELLV WELL REPLACEMENT M DESTRUCTION Ll Out of'..Service Well Ll <br /> PUMP INSTALLATION SYSTEM REPAIR C] C)THER�O Storing Well tl <br /> l ; <br /> r <br /> DISTANCE TO NEAREST: SEPTIC TANK tom_ SEWER LINES .2� DISPOSAL FLD.� PROP. LINE 20 <br /> I FOUNDATION 0 AGRICULTURE WELL 3IU2— OTHER WELL PITS/SUMPS _ <br /> M INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA ONS ,r <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Die. of Wall Excavation �� Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack 1Llracy Type of Casing Ak-1- Specifications <br /> Cl Public C ofelta Depth of Grout Seal fry �� <br /> r-I Irrigation - pfoJ COO Type of Groutlt�flfF4� <br /> Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done IJ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diametai Sealing Material & Depth <br /> F Depth 1/0' Filler Material i Depth O*p\U <br /> TYPE OF SEPTIC WORK; NEW INSTALLA N Ll REPAIR/ADDITION ❑ OESTRUCTI (No septic system permitted it public sewer is <br /> 1 available within 200 feet.) <br /> W <br /> Ihstilfation vvrfl serve: Residence Comma +aI Othar <br /> Number of living units: Number of bedroo <br /> Character of*oil to a depth of 3 feet: Water table depth <br /> y SEPTIC TANK. ❑ Type/Mfg.. Capacity No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED I-1 distance to neares • Well Fo dation Property Line <br /> I . <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distanw nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS 0 ,. <br /> I hereby comity 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 reguiations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of Calilornia." Contractor's hiring or subcontracting signature <br /> certifies the following; "I 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 o orn i <br /> The ap c IIto all requ a inspec ' s..Complete drawing on re r side, <br /> Signed Title: Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection byDote l -� <br /> Additional Comments: f t r- <br /> Applicant - Return all copies to: I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES !�»t� ✓�X ��✓ <br /> ..tENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES �� dt�•{Lu£e«. t/� �r•� <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 <br /> FEE i <br /> t INFO AMOUNT DUE t AMOUNT REWTTED CASH RECEIVED BY DATE PERMIT'NO. <br /> l ' <br /> . EH 13.24 tREV.r I n 5+ <br /> 14.26 f <br /> f H 't3.7`� \ \�.. 1 p-- ..-''iV ` 3? r <br />