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APPL I CATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <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 coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publi <br /> cHealth Services. f� /Gqr <br /> Job Address �`3�6 ��` Uri City d�'1 07Z Lot Size/Acreage r / q f <br /> Owner's Name+Dp2r- &_99'"JIj Address aly S UfC� 5'3�^ <br /> Phone <br /> /' <br /> ConIraC10 4 �L�� _j!/�1�1� Cp Address License Noes Z Phone 3 6/3 <br /> TYPE OF WELL/PUMP: NEW WELL.❑ WELL REPLACEMENT _ DESTRUCTION ❑ Out of Service He1I 0­ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well i7 <br />! DISTANCE TO NEAREST:'SEPTIC TANK �� f <br /> f „ _ - SEWER LINES (4�?—_ �' DISPOSAL FLD,L¢�± PROP. LINE 2„Q_ <br /> FOUNDATION _2,1_' ,.— AGRICULTURE WELL === OTHER WELL,. . PITS/SUMPS /6p—/ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONW <br /> n Industrial ❑ Open Bottom ❑ Manteca -"�"'bia. of Well Excavation"` "�!", _ 'pia, of Well Casiri <br /> Aq Domestic/Private Gravel Pack O Tracy Type of Casing ` Specifications ' X66 <br /> A Public C1 Other ❑ Delta Depth of Grout Seal Type of Grout• <br /> G Irrigation ?caO Approx. Depth Af I`Eastem Surface Saul Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done w <br /> i Well Destruction O Well Diameter"" Sealing-Material Z Depth-- <br /> Filler Materia114, Depth r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTiON CI (No septic system permitted if public sewer is <br /> % available within 200 fest.) <br /> Installation will serve: Residence— Gommerciaf Other 4 <br /> Number of living units: Number of bedrooms <br /> Character of tloil to a depth of 3 feet: <br /> ° Water table depth s <br /> SEPTIC TANK: p `Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, Cl Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED in Distance to nearest; Well Foundation Property Line f! <br /> SEEPAGE PITS 'I I Depth i Size _ __ _ Number <br /> SUMPS LI Distance to nearest: _Well Foundation Property Line } ;' <br /> DISPOSAL PONDS O 1 <br /> I hereby comity that I have prepared this application and that the work wilt be done in accordance with San Joaquin county Ogrdinances,'state taws, end <br /> rules and regulations of the San Joaquin County ' <br /> Home owner or licensed agent's signature cenifies 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," Contractoi 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 compansa- <br /> tion lawn of California." E <br /> The applicant mu call f ►ell require inspe, tions. Complete drawing on reverse side <br /> 1 e <br /> Signed ; Title: Dara{ �� f <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by 0 <br /> Data Area <br /> Pit or Grout Inspection by - f - Date !/ I �� ' ` ` :<, I f If �Q <br /> Fi f Inspection by• Data <br /> Additional Comments: / �.r✓ ` -� d f " <br /> �1� <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ✓'' r° /a,(,- <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES--:r-- <br /> 445 N SAN JOAQUIN, P 0 BOX -2009, 9TOCXTON, CA 85201 -. <br /> FEE <br /> AMOUNT.DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMiT'NO. � <br /> '� {�� qa of-�7y <br /> EH 114,26 �.+� 7 tf t <br /> r <br />