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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> } <br /> (Complete is Triplicate) <br /> Application is hereby made to Sart' wolethuSanCJoaquinfor <br /> county Ordinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> and thethe <br /> Rules andherein <br /> Regulatlono of Sans <br /> k <br /> application is Londe in caasplianc <br /> F Joaquin County Public Health Services. <br /> '� 1City Lot Size/Acreage !11 ,11:11 <br /> � •- <br /> k i>��� IM it aNt, <br /> Job Address t <br /> �Jc <br /> r Owner's Name ; <br /> Address a G L Phone <br /> .0 ;(� v. � ��� License Ivot�9q-�3-3__Phone T <br /> Contractor Ig T/ �� !tt Address t,oi' Ser_v_fce,fJell,Cl._. <br /> WELL-REPLACEMENT, C71 -.� — DESTRUCTION <br /> -�TYPE'OF WELL'/PUMPr NEW WELL - OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR C7 + <br /> ! O ! SEWER LINES ._ �- DISPOSAL FLD. PROP. LINE �— <br /> i DISTANCE TO NEAREST: SEPTIC TANK .— PITS/SUMPSf� <br /> FOUNDATION _ AGRICULTURE WELL + OTHER WELL_- <br /> ` i <br /> INTENDED USE TYPE OF�WELI PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Open Bottom [3 Manteca <br /> Dia. of Well Excavation <br /> f.l Industrial >T Pe � _� lt►G Specifications <br /> Type of Casing <br /> Domestic/Private -- ❑ Gravel Pack � C] Tracy � T of Groutq TT "'4" <br /> I7 Public f 1 Ojher ! ❑ Delta 1Depth of Grout Seal <br /> Cl Irrigation e -y ..APP a• Deplfi❑ Eastern S-urfaca.Seal Installed by ' t x r <br /> t t r o tate rk Do o eu. i�A <br /> I Repair Work Done 0 Typo, of Pump �s/' H•P•— <br /> G Well DierrtetBr~- Sealing Material,i, Depth , <br /> Well Destruction � J _ Filler ftterial''1, Depth <br /> Depth �C? - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0--.-REPAIRIADDITION 0- DESTRUCTION G 1No septic system permitted if public Bawer is <br /> available within 200 feet.) NQ <br /> I <br /> Installation will serve: Residence Commercials Other r'—ice f <br /> Number of living units: Number of bedrooms Water(able depth <br /> Character of soil to a depth of 3 feet: <br /> s Capacity No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Method of Disposal <br /> y 'PKG. TREATMENT PLT. 0 1 <br /> l Property Line e <br /> Distance to nearest: Well Foundation P Y <br /> f� <br /> Natal length/size <br /> LEACHING LINE Cl❑ No. &'Length of lines <br /> Property Line <br /> j'FILTER BED 1-1 Distance to nearest: Well Foundation <br /> SEEPAGE PITS 11 Depth Sire Number <br /> tProperty Line -- <br /> t !SUMPS L1 Distance to nearest: Well Foundation <br /> DISPOSAL PONDS <br /> will be done in accordance with San Joaquin county.ordinances, state laws, and <br /> I hereby comity that I have prepared this application and that the work <br /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that In the performance of the work for whish this permit is traced, f shall not <br /> hiring or sub-contracting signature <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor s <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 compenaa <br /> tion laws of California." <br /> ` The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signe AA <br /> doTitle: Date: ---,-- . <br /> OR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Date 7 Final Inspection by pats <br /> Pit or Grout Inspection by <br /> AdditionalComments: <br /> Applicant - Return all copies to: ENVIRONMENTALJOAQUIN OEALTHUNTY UHEALTHBLIC <br /> DIVISIONPERMBT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE GK �ECEIVED DATE PERMIT N0. <br /> �IINyFO AMOUNT DUE AMOUNT 1EMIT7ED CA5Nq _ <br /> An- <br /> r t <br /> EH 14.211 <br /> krD s� <br />