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APPLICATION FOR PERMIT r� .., d <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ; ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 SEP 2 <br /> (209} 468-3447 tri peQ�!�FPJT�'L; � <br /> R Rf>�l ii � �fAL <br /> i PM PATE ISSUIM <br /> ,." (Complete in Triplicate) ts <br /> " Application is hereby made,to SanlJoaquln County for a permit to construct and/or install the work herein described. This <br /> application in made in compliance Vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 4 ty a Site/Acreage <br /> D/Yf Address aP4_zl- 1hone <br /> Owner's Net P <br /> 7 con, : No�T Phone,?-?/ <br /> coG <br /> TYPE OF WELL/PUMP: NEW WELL WELL FE—PLACEMENY 0 DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER C] Monitoring Well �l <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> _ �-_- •-•...� .�- - _ = -- --_- -. _ _. �- - <br /> 1NTENDEO USE TYPE bF WELL PROBLEM AREA CONSTRUCTION SPEGiFICATI0N5s <br /> f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i <br /> >40mest ic/Private 0 Grayer Pack.. n Tracy Type of Casing Specifications <br /> M Public 1-1 Other © Delta Depth of Grout Seal Type of Grout <br /> C3 Irrigation —,Approx,-10epth Eastern Surface Seal Installed by <br /> r <br /> Repair Work Done ❑ Tyle of Pump I� H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth f <br /> Depth Filler Material i Depth } <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION JO REPAIR/ADDITION 0 DESTRUCTION CI (No septic system permitted if public sewer is � <br /> available within 200 feet.) W <br /> Installation will serve: Residence A Commercial— Other � <br /> Number of living units: Number of bedrooms. <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. Cl t ,µv:.4 '"� ) Method of Disposal <br /> y # <br /> Distance to nearest: Well Foundation Property Line <br /> -f LEACHING LINE 11 No. & Length'of lines Total length/size <br /> FILTER BED F1 Distance to nearest:- Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI ;Distance toFne9➢est: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �11 <br /> 4 .- <br /> Ihereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stela laws, and <br /> rules and regulations of the Sen Joaquin County.A <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 net <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> cenifies 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 compensa- <br /> tion laws of California." <br /> The applicant s call foraylirequired insPections. Complete drawing on rev se side. <br /> Signed - — Title: Date: - q1; q <br /> OR DEPARTMENT USE ONLY / J <br /> Application Accepted by Date Area <br /> r /7�f Q <br /> Pit or Grout Inspection by Final Inspection by �/ ' Date y •� <br /> Additional Comments: _gLk�zlf t 1-0690 //Z&/ <br /> Applicant - Returla all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONWENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 414.15 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY r� DATE PERMIT'NO. <br /> . EM 13.24 t11t'.V.v n el —J <br /> EH A-28 l zi, L <br /> 1 _ <br />