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ter.. <br /> t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 p•O BOX 2009TON �,VE- , PHONE STOCKTON, CA95201 <br /> 0 +3420 <br /> RES YEAR FR M D <br /> Rmn_(Comp <br /> late iia Triplicate) <br /> work <br /> in <br /> Application is hereby made', wiLhu9anCJoaquinor a permit to county-ordinancenstruct N.o 549gand 1862 and the nd,/or install eRules and eRegulations'describedoP Sans <br /> application is made in comp + <br /> Joaquin County Public Health Services. <br /> t I,at Sine/Acreage <br /> Job Address <br /> 23 ,, a City <br /> Phone <br /> [� Address <br /> Owner's Name ' ` ' <br /> License Na. Phone <br /> Address <br /> Contracter WELL REP!_ACEMENT C� DESTRUCTION it Out of, Service Well C3 <br /> NEW WELL ❑ OTHER © Monitoring Well } <br /> TYPE OF WELL/PUMP: — / SYSTEM REPAIR <br /> PUMP INSTALLATION W! DISPOSAL FLD. PROP. LINE <br /> SEWER LINES _— pITSlSUMPS <br /> DISTANCE TO:NEAREST: SEPTIC TANK -------- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION _ — <br /> INTENDED USE �. TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom C3 Manteca Die. of Well Excavation <br /> n industrial___.-� Specifications <br /> ❑ Gravel Pack ❑ Tracy Type of Casing - - ` <br /> ❑ Domestic/Private: Type of Grout �} <br /> J-1 Other C 1 Delta Depth of Grout Seal <br /> i'1 P lie x ace Seal Installed by <br /> I Irngauori F Approx De�th 1 I Eastern tJ� 'd <br /> t H.P. wr State Work Done 1' <br /> Repair Work Done ,❑ Type of Pump 1)I <br /> Sealing Flat r1a1 & th <br /> Well Destruction 10 Well Diameter Filler Material 6 Depth <br /> Depth <br /> F available within 200 feet.) <br /> TYPE 01 SEF 11C WORK: NEW INSTALLATION I 1 REPAIRIADDITIDN { I DESTRUCTION l I INo septic system permitted if public sewer is <br /> installation will serve: Residence Commercial _ Other ----- <br /> s.t _Number of bedrooms.- <br /> Number of living units:- Water table depth <br /> Character of soli to a depth of 3 feet: Capacity-- No. Compartments <br /> SEPTIC TANK. 0 Type/Mfg ." Method of Disposal <br /> PKG. TREATMENT PLT.I1 Foundation -- Property line------ <br /> Distance to nearest: Well , <br /> Total length/size <br /> LEACHING LINE ; Cl No. & Length of lines Foundation' _ Property Line <br /> FILTER BED CI Distance to nearest: Well <br /> . \Number <br /> SEEPAGE PITS I I Depth t Size * property Line <br /> SUMPS ..�x.� 1 <br /> Ll Distance to nearest: <br /> Welt Foundation �— <br /> DISPOSAL PONDS ❑ ,i <br /> I I hereby certify that I Neve prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Countyify that in the <br /> f the work for <br /> this permit is <br /> issue <br /> Home owner or licensed agent's signature sign to became subject following: <br /> Ingg <br /> : "I cert compensation laswsoof California."rmance oContractor's ihiring or sub•cont acttiidngl signature <br /> employsuch <br /> anner <br /> employ any per n <br /> certifies the f wing: "I certify that in t e performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion <br /> nmpens -tion laws of lifornla ' <br /> The applica must c req ' nspections. Complete drawing an roverie�side. r <br /> Date: <br /> Title: <br /> Signed <br /> F DEPARTM T USE ONLY <br /> Date S r 4 - Area l <br /> Application Accepted by Date Final inspection by <br /> Date4LO#/ <br /> Pit or Grout Inspection by <br /> �-- <br /> Additional Comments: s <br /> kApplicant - Return all copies to- San Joaquin vitmnmeanta,liHealthtPermit/Services <br /> Serv1601 E. Hazelton Ave.. P D Box 2009, Stockton, CA 952D1 <br /> CK RECEIVED BY DATE AERMfT'NO. <br /> E <br /> FEAMOUNT DUE AMOUNT REMITTED CASH <br /> I o I_! r9 <br /> r 1jS.oo <br /> a £H 13-2A)REV.t/N 5f <br /> EH 11.26 <br />