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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON , CA 95201 <br /> (209) 468- 8420 <br /> R FROM DATE ISSUED. <br /> (Complete in Triplicate) <br /> Application is hereby made to Sas Joaquin County for a permit to construct and/or install the work herein described This <br /> application is made in cozplianee with San Joaquin County Ordinance No. 549 and 186 and the Rules and Regulations of San <br /> Joaquin County Public Health Services �1_ /A P/V /��2,s--3! <br /> Job Address �' Oreo 0111 � 7 Lot 31 to/Acreage <br /> Owner a Nam r Address 1461ty Feem�f1 5Phan 6-0131-t <br /> ��1} GJ�7bG l <br /> Conttaclor V Address �rrn��� ('�r.(��n 95G7Q License No Phone -71&Y <br /> TYPE OF WELL/PUMP NEW WELL X( WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK �Y SEWER LINES 612 r DISPOSAL FLD .1112.4 PROP LINE 2�> <br /> FOUNDATION _A2____ AGRICULTURE WELL ,&YZ OTHER WELLAZd - PITSISUMPS e <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fn Industrial ❑ Open Bottom O Manteca Dia of Well Excavation " Dra of Well Casing <br /> Domestic/Private XGravel Pack 0 Tracy Type of Casing- C' Specification.-. <br /> D Public 11 Other ❑ Delta Depth of Grout Seal f CST Type of Grout <br /> CJ lnru4uon Approx Depth ❑ Eastern Surface Seal Installed by 7 <br /> Repair Work Done L3 Type of Pump H P State Work Dona _ <br /> Wait Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material L Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION Q REPAIRIAbDITION ❑ DESTRUCTION G (No septic system permitted if public sdwar is <br /> available within 200 last I <br /> �tallation will serve Residence^ Commercial_ Other <br /> mber of Irving units Number of bedrooms <br /> Character of sod to a depth of 3 feet —Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity._.._. No Compartments <br /> PKG TREATMENT PLT,0 Method of Disposal <br /> Distance to nearest Well Foundation Propany Line <br /> LEACHING LINE 0 No & Length of Imes _ Total length/size- <br /> FILTER BED n Distance to nearest Well Foundation Property Lina <br /> SEEPAGE PITS 11 Depth Sue — Number <br /> SUMPS LI Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hareby certify that I have prepared this application and that the work will be done in acceroance with San Joaquin county ordinances, state laws and <br /> rules and regulations of the San.Joaquin County <br /> Home Owns( or licensed agent a signature certifies the following I candy that in the perlormance of the work for which this permit 13 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 sub contracting signature <br /> certifies the following 'I Certify that in the pefiormanee of the work for which this permit is towed I snail employ persons subject to workman s compansa <br /> lion laws of California " <br /> The appitcant pu t at r all requi In pections Complete drawing on reverse slide <br /> Signed Title Cm? lk' Date 7 ,? <br /> FOR DEPARTMENT USE ONLY <br /> Application Ac aptsd by Data Area <br /> Pit or Grout Inspection by Date Final Intpaction by Date <br /> Itional Comments <br /> licant - Return all copies to, SAN JOAQUIN COUNTY PUBLIC HEALTH SERViCLS <br /> ENVIRONMENTAL HEALTH DIVISION PERUIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVEO BY DATE PERMIT NO <br /> EK 13 74 IAfv ulolr <br /> EH 4 m <br />