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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 46$--84 7,3''/-2O <br /> R <br /> (Complete in Triplicate) <br /> Application is hereby made to Sao Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance' vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Ser ices.1 <br /> Job Address L l' `� r1 � � 1610city Let Sise/Acreage <br /> ' � YOwner's Name^ r'''y v{ A dress 6, "`�' •��' € 4D Phone <br /> -woCOrttractor_ Address 1c License NO3 ,S Phone L- � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C"1 DESTRUCTION ❑ Out of Service Stell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR E*---" OTHER ❑ Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._- PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1771 Industrial C5'0 pen Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing .w <br /> U Domestic/Private Cl Gravel Pack' ❑ Tracy Type of Casingr <br /> Specifications <br /> ❑ Public Cl Other ❑ Delta Depth of Grout Sea! Type of Grout <br /> m trri-oation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done L] Type of Pump H.P. State Work Done_ <br /> Well'Destruction D Well Diameter Sealing Material A Depth <br /> 1k Depth Filler 1lftiei isl'i'Dej?tlti �---�----� _. <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION CI (No septic stem <br /> f P Y permitted if public sewer is � <br /> available within 200 feet.) - <br /> Instsllation will serve; Residence_ _ Commercial _ Other <br /> Number of living units: Number of,beds omst""'-'' <br /> &VIsctsr of soil to a depth of 3 fent: <br /> F F Water table depth <br /> a SEPTIC TANK. ❑ Type/Mfg v Capacity _ No. Compartments <br /> PKG�TREATMENT PLT. C] " 4 a/� Method of Dispose! I <br /> q . Distance to nearest:' 'rWel! Property Line- <br /> 4 55 } Foundation. <br /> "BEACHING LINE ❑ No. 6 Length of lines F Total length/size t <br /> j-FILTER BED C1 distance to nearest: Well Foundation -- <br /> *:' Property Line <br /> SEEPAGE PITS 11 Depth `--silo' *-»-�-- } r <br /> Number <br /> SUMPS Ll Distance to nearest: Well Foundetion :; - - Property Lrne <br /> DISPOSAL PONDS ❑ <br /> l 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 /> rule's and lag tions pf thle'$an'Jo6gtiin <br /> Homo owner or 'canoed agent's signature Certifies tfie followin I certify'that.in the a k <br /> g:... , performance of the work for which this permit is issued, I shall not <br /> employ any ran in such nner as to bec a subject to"warkmbri's compensation laws of California:',Contractor's hiring or sub-contracting signature <br /> certifies the f llo ing: "t C rn th tint ri fmirtce flthe-woik'-for which this ermit is issued, I shall employ <br /> tion laws of I ornia.,, p p Y Parsons subject to workman's compenaa• <br /> The applica 1 M If all r uired 'ns io C plate drawing on rev;rss Side. ( # <br /> Signed 1-Title: ` <br /> Date: A <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by j <br /> Date Z <br /> Area <br /> Plt or Grout Inspection� by Date Final inspection by Date / <br /> i Additional Comments: <br /> : _ t <br /> j Applicant - Return all copies to: SyN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, $TOCKTDN, CA 85201 <br /> a <br /> FEE AMOUNT DUE JJ AMOUNT REMITTED <br /> INFO t CASH JECEIVED By DATE PERMIT'NO, <br /> EH'4' 4� V <br /> 241REV.I/KSI V <br /> EH:�.Te I V J <br />