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APPLICATION FOR PERMIT / 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> REMIT UPI-RES I YEAR r9QM PATE ISSUBP <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in castpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San r <br /> Joaquin County Public Health Services. / X ( i <br /> Job Address ? Cit y4-'c��!� Lot Size/Acreage <br /> /3lG� Address Phone `V` 3120 <br /> Owner's Name . <br /> /�� 773 " y-4�7 iJ' <br /> Contractor���� 16719] f Address ��6Y �2 License No� Phone i <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT F DESTRUCTION t of Service Well 0 j <br /> PUMP INSTALLATION T&� SYSTEM REPAIR ❑ OTHE ❑ Monitoring Well C7 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Sy t DISPOSAL FLO. PROP. LINE A630— <br /> FOUNDATION AGRICULTURE WELL OTHER WELL en PITS/SUMPS _. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom O Manteca Die. of Well Excavation Dia. of Well Casing <br /> >epomestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F— <br /> M Public f 7 Other © Delta Depth of Grout Seal, .00 _ Typi of Grout Clt^ _ <br /> ' .' \ F <br /> CI IrriUation / tf�Approx. Depth 0 Eastern _ • Surface Seal_Inslalled by - <br /> Repair Work Done fJ Type of Pump .._ H.P, - State Work Done 574 <br /> Welt Destruction ❑ Well Diameter Sealing Material ir�Depth `�1� <br /> Depth Filler Material & Depth �• - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION 0 DESTRUCTION M (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> installation will serve: Residence — Commercial.-.- Other <br /> Number of living units: Number of bedrooms °}fi <br /> Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC TANK.j ❑ Type/Mfg _ �.. -- r Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 �f ry Method of Disposal <br /> Distance to nearest: Well Foundation _Property.Line <br /> t i i rf= <br /> LEACHING LINE I ❑ No. & Length of lines Total length/size <br /> FILTER BED [l Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Site Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> fules and regulations of the San Joaquin County f <br /> Home owner or licensed agent's signature certifies the following: "I Certify that in the performance of the work for which this pirmit is issued, I shall 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 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 compansa• <br /> tion laws of California." , <br /> The applicant must call for II require inspections. Complete drawing on reverse side. <br /> Signed X_, .�� _ Title: Date: <br /> r <br /> DEPARTMENT USE ONLY f <br /> Application Accepted by _ Date <br /> Data <br /> Pit rout I spection by�� Dat S Final Inspection by d <br /> Additional Comments: ��-tl � Lx w QC, } bt <br /> - <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 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVES] 9Y DATE PERMIT'NO, 7� <br /> INFO �yp� CASH � �/�] G /'] /{~_p/� ���..'JJ`^J��JJ` <br /> EH 13 24 IREV.1104 3� .6C� oo ✓�'' i 0�= `l1r\L7 r� <br /> EM;41a ff <br />