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APPLICATION FOR PERMIT <br /> . SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL allALTH DIVISION <br /> # P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 ' <br /> Y <br /> (Complete in: Triplicate) <br /> Application is hereby mede'to Saa Joaquin County for a '2work herin 9 0,3 <br /> application Is made in C0411ance with SanjJoaquin County OrdinancenNO. 549aando1862aand theeRules andeRegulationedof Sang <br /> Joaquin Count Public Health Services. �� <br /> OJT -.� .. <br /> Job Address <br /> ` Ciry Lot Size/Acreage <br /> �u *f 4Cv7o ACur/`t 9'F5 P4 <br /> Owner's Name Address Phonea✓ <br /> ';r' <br /> Ontractor .Address � <br /> TYPE OF WELL/PUMP: License No. Phone <br /> NEW WELL © WELL REPLACEMENT Cl OESTRUCTI t of Service Well ❑ <br /> PUMP INSTALLATION ❑ i :SYSTEM REPAIR C] OTHE Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESt FL <br /> �w D15POSAL D. PROP. LIME <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFIC4TlQNS <br /> f,,3,Industrial O Open Bottom t �'�" <br /> Pe O Manteca Dia, of Well Excavation_ Dia. Of Well Casing <br /> �mestic/Private C! Gravel Pack:I t ❑ATracy Type of Casing <br /> ;bite Cl Other ' Specifications <br /> LJ Delta Depth of Grout Seal Type of-Grout <br /> G irrigation Approx. Depth ❑ Eastern - I <br /> Surface Seal Installed by <br /> Repair Work Done. 0 Type of Pump: H P <br /> Stats Work Dona <br /> Well Destruction O Well DiameterSealing Material i Depth <br /> _ <br /> O <br /> Depth Filler Material i Depth I� <br /> TYPE OF'SEPTIC WORK: NEW INSTALLA I IUN.CI REPAIRIADDITION C1 DESTRUCTiON (No septic system permitted if pTrblic sewer is <br /> Instsilstion will terve: Residence Commercial available within 200 feet.1 <br /> Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg. Ca tit Pfd <br /> PKG. TREATMENT PLT,❑ Y No- Compartments - y <br /> Distance to nearest: Well Method of Disposal t� <br /> Foundation_--�_.Property Line <br /> LEACHING LINE ❑ No. & Length of !'rues <br /> FILTER BED Total length/sire �— <br /> n Distance to nearesC Well Foundation <br /> 1 Property Line \ I <br /> SEEPAGE PITS 11 Depth " r C <br /> Sire Number <br /> SUMPS LI Distance to nearest: Well _ `_ <br /> DISPOSAL PONDS p 3 Foundation T Property Line _ t <br /> I hereby cenity that 1 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 San Joaquin County - J <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the Performance of the work for which this permit is issued, I shall not Q <br /> employ any person in such manner as so become subject to workman's compensation laws of California," Contractor's hiring or stub contracting signature <br /> certifies the following; "I certifythat in the Performance of the work for which this permit is issued, I shall am to I <br /> tion law$of California." P <br /> p y persona subject to workman's comPensa- ' <br /> The applicjIntAnust call for all requir spec 'ons. Complete drawing on reverse fide. "! <br /> Signed a �` <br /> Title- <br /> Date:' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit of Grout Inspection b Date <br /> _ ----.�_, Final Inspection by Date <br /> Additional Comments: E r•Z n t� was ' <br /> Applicant — Returp all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON. CA 95201 <br /> INFO FEE AMOUNT OUE 1AMOUNT REM+T r CK <br /> CASH RECEIVElEliMEH 1 •24IIIEV.i/NEN:4.� <br />