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APPLICATION FOR PERMIT <br /> ✓ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��'� '? <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOB 2009, STOCKTON, CA 95201 ; <br /> (209) 468-3447Nod/ <br /> F0 <br /> YEAR ff�� t 1990 <br /> (Complete in Triplicate) <br /> Pr- <br /> (Complete L]" <br /> Application is hereby made'to San Joaquin County for a permit to construct and/or install the work herein a +'phis <br /> application is made in coupliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulati�of San <br /> Joaquin Count blit Health Services. <br /> !Z!2 <br /> Job Address /a) City Lot Size/Acreage <br /> Owner4sNaL,&,?�"�' v Addres r �%!!�L ° "Phone� ! IblAy"W" No Phone <br /> Phoned <br /> TYPE OF WELL/PUMP: NEW WELLLEn WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAY OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> meatic/Private I-) Gravel Pack, ❑ Tracy Type of Casing t Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation —Approx. Depth D Eastern Surface Sedl Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Wall Destruction ❑ Well Diameter Sealing Material A Depth L <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION 0 DESTRUCTION CI IN-6 septic system permitted if public sewer is <br /> avilable within 200 feet.) <br /> - .,.. —Instaftstion-will some: Residence-__z:—Commercial — Other <br /> Number of living units: Number of bedrooms <br /> Character of&oil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. ZREATMENT PLT,C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED [) Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth *S6ee_ <br /> SUMPS U Distance to nearest: Well ` Foundation Property Line <br /> DISPOSAL PONDS ❑ Y"` ' <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 /> 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 /> employ any person in such manner as to become subject to workman's.-compensaiion laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the wor0or whichthis permit is issuednI-shill employ persons subject to workman's companaa• <br /> tion laws of California." - -The applican s c:d -r uire'd ' `sections. Complete drawing on re rse e <br /> Sign Title: Date: <br /> F DEPARTMENT USE ON <br /> II Application Accepted by Date _ i' / ~�U _ Area <br /> Pit or Grout Inspection by Date Final Inspec ' n b,--5- ,- L Date Z <br /> Additional Comments; <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t. ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RCK ECEIVED BY a DATE PERMIT NO. <br /> 4 V <br /> + CH 13-24 IRty.Rhyl t/ t• V <br />