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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> • ENVIRONldENTAL HEALTH DIVISION <br /> 1601 E. BOX 2009/, STOCKTON, CA <br /> V095201-3420 y <br /> PERMIT g3jpIRSS 1 YEAR FROit DATE T CF:i f <br /> (Complete In Trip11CIL—i <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This f <br /> application is made in compliance with San Joaquin County Ordirunce No. 549 and 1862 and the Rules and Regulations of Sen <br /> Joaquin County Public Health Services. <br /> City <br /> 1 Lot Size/Acreage <br /> I5b51 1/NN � <br /> Job Address <br /> Phone <br /> Address . <br /> owner's Name � <br /> License No. Phone ( ; <br /> Contractor Address ❑ <br /> WELL REPLACEMENT G DESTRUCTION ❑ pat of Service Well �- i <br /> TYPE OF WELLI PUMP: N£W WELL G OTHER G Monitoring Nell G <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR C1 <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Fj <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation (/ <br /> G Industrial Type of Casing Specifications <br /> ❑ Domestic/Private G Gravel Pack G Tracy Type of Grout <br /> I'I Public <br /> ❑ Other n Delta Depth of Grout Seal <br /> -I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed bV <br /> P State Work Oone i— <br /> Repair Work Done L3 Type Pump H Sealing Material i Depth <br /> Well Destruction <br /> n O Well Diameter 1 <br /> Filler Material i Depth <br /> Depth <br /> • TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRtAODI710N I I DESTRUCTION I available wit h n 200 falseptic stem l.) d public sewer rs .." <br /> / <br /> Installation will some: Residence)L Commercial_ Other Q` <br /> Number of living units: __ Number of bedrooms Water table depth 14V <br /> Character of sell to a da_pm/,o(3 feet: CapacRy.Lita+.xi— No. Compartments <br /> SEPTIC TANK. 61' type/Mfg <br /> f Method of Disposal ^_ <br /> PKG. TREATMENT PLT. G ' <br /> Defence to nearest: Well Foundation �� Property Lina y�0 <br /> LEACHING LINE No. i Length of lines 3 Qa' QD I �I Topt length/sue 5 S t <br /> Foundation 2S t Property Line <br /> FILTER.BED G Distance to nearest: Well , <br /> I Depth 'f Sixa 'I Number 3 r <br /> SEEPAGE PITS ' <br /> SUMPS El Distance to nearest: Well 2oO Fountlation Sy Property Line <br /> DISPOSAL PONDS ❑ ` <br /> work will be done in accordance with San Joaquin County ordinances, state laws, and <br /> I hereby certify that/he"prepared this application and that the <br /> i rules and regulations of the San Joaquin County 1 shall not <br /> Home owner pr licensed agent's signature certifies the following: "I certify that in the performance of.Cnce of the work for which this perms is issued, <br /> employ any person in such manner as to become subject to workman's compensation laws issued, <br /> I shall <br /> ploy er osnsls�ub ct to workman's tompensa. <br /> certifies the fallowing: -I certify that m the performance of the work for which this permit is iasuad,1 shall employ pe I <br /> tion laws of California." <br /> II The sp ' t must caB4or�'ap�,requwad inspections. Complete drawing on reverse side. <br /> W <br /> Signed <br /> 1 %s-_n•_ ^ n nOn Title: Date: <br /> FOf ARTMENT USE ONLY <br /> -� Date �-" -V C Area 1 <br /> Application Accepted by <br /> f�N Date on by <br /> or Grout Inspection by <br /> v Final Inapect <br /> Ai Comments: <br /> Applicant - RELIiI'p all copies to: Sen Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P D Box 2009, Stockton, CA 95201 <br /> S CK RECEIVED BY DATE PERMIT NO. <br /> FEE MOUNT DUE M70 <br /> ITTEO CASH �y <br /> f INFO L�ll ! (J 1,--13•7 /✓ <br />