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ADPLICATsON FOR PERU IT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 9520 . <br /> (209) 468-3447 i <br /> PTs321[T'f' ERPIRES 1 YEAR e909 DATA} j.SSUW i <br /> (Complete in Triplicate) ( 01 —De o 52 <br /> Application is hereby made•to San Joequin County for a permit to construct and/or install the pork herein described. This <br /> application is made in cou liancefvith San Joaquin,County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 2%✓.< <br /> Job Address <br /> :'¢ v g g City fry D Lot Size/Acreage <br /> _ q.r,,z O Cis <br /> OwnAr'.s.Nems I Address.-�i <br /> ----Phone <br /> • Contractor ./^j <br /> jf�k) Address M- License Noc ,_Phone <br /> 21117 -1 7?q <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT .n DESTRUCTION Out of Service Well 0 <br /> Monitoring Well <br /> PUMP INSTALLATION ❑. rte <br /> SYSTEM REPAIR C. OTHER ❑ �� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE re <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ^' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Wait Excavation Dia. Well Casing <br /> ,Cj-DomesticIP_rivate.— -D-.Gravel-Pack. 0--Tracy�T.ype of-Casing-- m - — -Specifications <br /> C3 Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> C 0 lrriUation Approx;"rDepth ❑ Eastern 'Surfice.Serrl-Installed by <br /> XL r Repair Work Done U Type of Pump �H.P• " "" S`atq Work Do e <br /> Weil Destruction Well Diametarl- sealing 1Katerial i Depth /� Q - vw P <br /> x� <br /> Depth- ��-�LPiJ'J!Q r Filler N'terial i Depth <br /> TYPE OF SEPTIC WORK: NEW"INSTALLATION 0 ,REPAIR/ADDITION C" DESTRUCTION G INo septic system permitted if public sewer is <br /> { available within 200 feet.) <br /> Installation wili serve, Residence—` Commercial— Other <br /> Number of living units: Numger of bedrooms ! ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK"- ❑ Type/Mfg ' Capacity No. Compartments <br /> I PKG. TREATMENT PLT, C1 x Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE Cl No. A Length of lines Total length/sire <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> J <br /> 4� SEEPAGE PITS l I Depth ' Size Number <br /> 4 SUMPS LI Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS 0 -I <br /> r I 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 /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such mariner as W,become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> comilies the following: "I certify that 4%the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> Ilon laws of California." I I <br /> The applicant must call for all requ ed inspections. Complete drawing on reverse side. <br /> • # crZ� <br /> Signer Jilt t [I pQ,�- Title: Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data <br /> �4 Area 41 SSBI` <br /> f I ✓ U, <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by - <br /> Date <br /> F .. <br /> Additional Comments: <br /> F Applicant - Return all copies to. SAN JOAQUIN COUNTY P C HEALTH SERVICES <br /> EN"VIRONIIENTAL�HEALTH-DIVISION-PERHIT/SERVICES <br /> 445 H SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 i <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EH13-24 AtPEV.rin3r /.O NF <br /> EH;44626 <br />