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APPLICATION FOR PERMIT <br /> SAN JOAQ NTHEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION _342 0 <br /> 1601 E. AVg <br /> 9)468 <br /> poBOX2009, STOCKTON, CA 95201 <br /> � <br /> Egg RTS 1 YEAR FR 1d D <br /> (Complete in Triplicate) <br /> vorX <br /> in <br /> A lication is'hereby made to San Joaquin County foCou permit <br /> din%neeconstruct <br /> No. 549gand1862saandltheeRules and Regulationsdof Sans <br /> pP ! <br /> application is made in compliance with Asn Joaquin Y 46 J <br /> __ <br /> � <br /> Joaquin County Public Health Services. <br /> fill J JL � •� City Lot Size/Acreage C <br /> Job Address / [fl phoner- <br /> �'e L:��� :,,'1 � Address - , .- f-r, - - _ <br /> Owner's Name _ __.� Q3f <br /> -- � 7 Y License No. ' > Phone <br /> Address y put of Service Well ❑ <br /> Contractor WELL REPLACE ENT G] DESTRUCTION ❑ <br />'I NEW WELL ❑ OTHER ❑ Monitoring Well C1 <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR 11 <br /> PUMP INSTALLATION ❑ <br /> ESEWER LINES �------ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK -- PITSISUMPS <br /> FOUNDATION ---- AGRICULTURE WELL . OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Bottom Manteca Dia. of Well Excavation <br /> ❑ Open <br /> n Industrial 7 e of Casing. Specifications <br /> ` f7 DomesticlPrivate ❑ Gravel Pack ❑ Tracy Yp Type of Grout <br /> f (-1 Other Cl Delta Depth of•Grout Seal <br /> I'I Public <br /> x. Depth ! I Eastern Surface Seal installed S <br /> i I Irrigation —.Approtate Work Done <br /> s H.P. <br /> Repair Work Done U TYPE of Pump Sealing Material & Depth �J <br /> Well Destruction ❑ Well Diameter �� Filler Material & Depth fA <br /> 4' Depth - <br /> TYPE OF SEPTIC WORK: NEW-INSTALLATION REPAIRIADDt11 710N I I DESTRUCTION I I INaiI bi wit 200 feet.) If public sewer is <br /> ' 1L r <br /> Installation will serve: •Residence Commercial Other <br /> Number of living units: Number of djo s��- JCQ <br /> f Water table depth <br /> Character of soil to a depth of 3 feet: �I j Capacity No. Compartments <br /> SEPTIC TANK ❑ = Type/Mfg <br /> -(40 Method of Disposal <br /> PKG. TREATMENT,PLT.❑. property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size <br /> LEACHING LINE J �No. A Length of lines <br /> r" Property Line <br /> FILTER BED ❑ Distance to nearest: ell Foundation -- <br /> , ✓" x� -) <br /> 01 Depth Size Number <br /> SEEPAGE PITS Property Line C <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ <br /> will be done in accordance with San Joaquin county ordinances,I heteb; state taws, and <br /> certify that I have prepared this application and that the work <br /> rules and regulations 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 /> s of <br /> employ any personin such manner hat n the performance of subject to <br /> work an Is for <br /> which this permit is issued,fl shall employaperrsonslring or subject to woorkman�s.ccornpensa- <br /> certifies the following: Y <br /> tion laws of California." <br /> ctio s omplete awing on reverse side. f` f <br /> The applicant must call for all re a spa 4 � <br /> Title: �Zh �� Date: <br /> $i <br /> r F DEPARTMENT USE ONLY Q <br /> _.. Date __ \ - - Area <br /> ' Application Accepted by <br /> Pit or Grout Inspection by Date�.�--- <br /> Final inspection by Dete � 23 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE FERMII'NO, <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> kN,fO)) r <br /> . EH 13-24 TREY,IIM51 A! <br /> EH'14-2r1 r�r <br />