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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) 4683447 <br /> RES 1 R <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in covliance with San Joaquin County Ordinance No. 51+9 and.1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. I <br /> S� LSr7�f City_ S7 4,,L/ Lot Size/Acreage <br /> Job Address � � .� - <br /> �7 Phone Cv y r 3 <br /> Owner's Name , Sm 16 V /l7Al�S/1 Address <br /> �6 =3 7' <br /> Contractor r�y� Address G c�. License No. � ���� _ Phone <br /> WELL REPLACEM n DESTRUCTION ❑ Out of Service We11 11 ❑ <br /> TYPE OF WELL/PUMP: _ NEW ELL ❑ OTHER ❑ Monitoring [I <br /> PUMP INSTALLATI ❑ SYSTEM PAIR ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �.�_ GRICULTUR ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> y C' industrial ❑ Open Bottom ❑ Manteca is. of Well Excavation <br /> 7y of Casin ` Specifications <br /> t U Domestic/Private ❑ Gravel Pack 0 Trac g Type of Grout <br /> t <br /> I I.3 Public I�1 Other ❑ D a Depth o rout ea <br />'1 G Irrigation Approx, Depth Eastern Surface Soul tailed by <br /> b Repair Work Done L3 Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Wait Diameter <br /> 3esling Material & Depth <br /> Depth Filler Material i Depth V) <br /> TYPE 4F.SEPTIC WORK: NEW INSTALLATION❑ <br /> REPAIR/ DESTRUCTION C1 avfailablleseptic <br /> w thin 200 permitted it public sewer is <br /> f , <br /> Installation will serve: Residence ' Commercial_ Other <br /> Number of living units: --I-.._ Number of bedrooms 21v <br /> + Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg A 16- --Capacity No. Compartments <br /> PKG. TREATMENT PLT.C) I Method of Disposal <br /> Distance tolriearvi Well Foundation Property Line <br /> 'r) <br /> LEACHING LINE No. A Length,of linos" Z —A47 � f Total length/size � <br /> FILTER BED n Dista-to nearest: Well fr9CCl-� Foundation `�-�� Property Line �.— <br /> SEEPAGE PITS I { Depth ._�--��-- _Site � _ Number <br /> „.. �.� <br /> sumps LI Distance to nearest: Well Foundtitian. 3 U' _— Property Line <br /> DISPOSAL PONDS- ❑ <br /> I hereby certify`lhat 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 Sen 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 /> f employ any person in such manner as td 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 compsnsa <br /> tion laws of Californiar"_ ; <br /> j The applicant moat call or all required'inspecitti�onss, Com drawing on reverse side. <br /> Signed <br /> w�..�:Title: � Date: <br /> 'FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date " Final Inspection by Data 2 <br /> f ✓- <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUTN C6UNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON. CA 95201 <br /> FEE ;0k <br /> UNT DUE AMOUNT REMITTED CASHt:—:::j <br /> CEIVED aY DATE RMIT NO. <br /> INFO Q s6 g ` -{ c 11y•� '3 0`CJ t° Zl, iTt <br /> ^ <br /> FH;{•]e <br />