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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION PA y <br /> P O BOX 2009, STOCKTON, CA 95201 ��. <br /> ftc <br /> (209) 468-3447 L�aveo <br /> MAY PERMIT EXPIREa I YEAR ER z ,^� <br /> (Complete in Triplicate) ��� IVry <br /> Pu,0H DATE ISSUED 0I <br /> �/1 QU11VCO�Vr <br /> Application is hereby made to San Joaquin County for a permit to construct and/or inatall the Vn SAI T SEftift This <br /> application is made in eompllance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules sad San <br /> Joaquin County Public Health Services. o�- <br /> Job Address IWO f F 1 S+rte" City �ock�Qn Lot Site/Acreage <br /> Owner's Name I ?x Address D L Sion�- Vd. JCACj' Phone 37Z-Q <br /> b no <br /> ContractorA C Address 5 E M �' • S��itc onNI- Cs -51ZZ6 hone�2 5271Z <br /> TYPE Of WELL/PUMP: NEW WELL JS WELL REPLACEMEN'T ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK . '50 SEWER LINES 50 f DISPOSAL FLO250 PROP. LINE <br /> FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS ?_ab <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tr <br /> [I Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 8 Dia. of Well Casing <br /> U Domestic/Private 9Gravel Pack ❑ Tracy Type of Casing 'PVC Specifications b5-80'1 <br /> * Public CC1 Other in Delta Depth of Grout Seal Type of Grou �.ment'b;rl n <br /> C3 I��ali n Y•Ylq A Ll Approx. Depth ❑ Eastern Surfs a Seal Installed by • <br /> on <br /> Repan WI doj U Type of Pump H.P. N State Wk Done <br /> Well Destruction O Well Diameter A „ sealing Material i Depth <br /> Depth Filler Material i Depth N A <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIWADDITION tri DESTRUCTION F-I (No septic system permitted if public sewer is <br /> available within 200 teal.l ,ter <br /> Installation will serve: Residence Commercial_ Other V . <br /> Number of living units: Number of bedrooms IM <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No: Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i l Depth Size 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 /> rules and regulations of the Sen Joaquin County <br /> Home owner or licensed agent's signature cartifies 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 compensation laws of California." Contractor's hiring or subcontracting 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 compensa- <br /> tion laws f California." <br /> The appNc t m all f r wired inspections. Complete drawing on reverse side: ` <br /> Signed ` Title: Q Date: !� <br /> FOR DEPARTMENT US ONLY Q <br /> Appticatio ccepted by Dat �Z� Area <br /> Pit or Grout Inspection by Date i4 Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PPRMIIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCILTON, CA 95201 <br /> Ik iT <br /> EEE AMOUNT DUE AMOUNT <br /> REMrTTED //CASH DECEIVED BY �! DATE PEFIM17'NO, <br /> . EH l�- 1REV,I/11151 U7,(� gg""v IV ciJCJ :/' � +J <br />