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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUB <br /> LIC HEALTH SERVICE�lfl_ rs ' � ' <br /> ENVIRONMENTAL HEALTH DIVISION NOV 2 <br /> S ' 0 <br /> P O BOX 2009, STOCXTON, CA 95201 `v�' ElC)E� IT�1 HA4.. E(209) 468-3447 <br /> R <br /> PERM T•/SERVIC ES <br /> {Complete in Triplicate) <br /> vork <br /> in <br /> Application is herebynmade.toaSen yithuSanCJooaaquinfor <br /> county ordinanceconstruct <br /> No. 5498andp1662 and thr install e Rules aadeRegulations dof San <br /> s <br /> application in mad CMp <br /> nce <br /> Joaquin County Public Health Services. <br /> • � City� Lot Size/Acreage <br /> Job Address F <br /> L � Phone I <br /> p1�( c ddress I <br /> Owner's Name 1L1� � g.y �ii7(p I <br /> O License No. � ��'"�'_Phone <br /> Contracto A� Addressof Service well <br /> TYPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out Monitoring Well <br /> TI Ni�, SYSTEM REPAIR OTHER ❑ <br /> PUMP INS I ALLA 0 i S— - . LINE <br /> SEWER LINES ___ <br /> DISPOSAL FLD, <br /> PROP <br /> DISTANCE TO NEAREST; SEPTIC TANK _�-- T._... .__ �PITS�/SUM PS'•..,"'" " <br /> --� - -'. "FOUNDATION�..-. <br /> AGRICULTURE�WELL�" •OTHER-WELL" <br /> ,�. <br /> INTENDED USE TYPE OF WELT PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> n Industrial ❑ Open Bottom <br /> Dia. of Well Excavation <br /> EI Manteca Type of Casing Specifications <br /> ���J <br /> 1 t_omssticlPrivate D Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> R Public CI Other 0 Delta N-1 <br /> Approx, Depth Ci Eastern `3/(l( <br /> Surface Said Installed by <br /> fi Gi IrriUation � State Work Done <br /> Repair Work Done �Type of Pump H.P. Oi\ <br /> $eay Material i Depth <br /> Weil Destruction O Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE: OF SEPTIC WORK; NEW INSTALLATION L7. REPAIRlADOITION 0 DESTRUCTION CI (No s ptic thin m fewrned if publicavasewer is <br /> " installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of *oil to's depth of 3 feet:K ❑ Type/Mfg __ No: Compartments <br /> j SEPTIC TAN - - Capacity �- <br /> I Method of Disposal <br /> 'PKG:•TREATMENT PLT. 0 3.... <br /> Distance to nearest: Well "{ Foundation Property Line — <br /> LEACHING LINE Cl No, 6 Length of lines Total length/sire <br /> I �R�..x <br /> f FILTER BED n Distance to nearest: Well dation Property Lina_ <br /> SEEPAGE PITS 11 Depth Siva Number <br /> _ LI Distance to nearest: Well Foundation Property Line ,, <br /> SUMPS _ <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, stale laws, and <br /> I hereby certify that I have prepared osis application and <br /> rules and regulations of the San Joaquin County <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 <br /> employ any person in such manner as to becoma subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must ca for all required insp.coons. Complete drawing on re arse side. T. <br /> Title: �r Date:._ 7I yo <br /> SignedX <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by I(p <br /> Pit or Grout Inspection by Date — Final Inspection by <br /> 4A= <br /> Data <br /> Additional Comments: <br /> Applicant - Return all copies to: TH SERVICES <br /> ENVIRONMENTALJOAQUIN OPUBLICUNTY <br /> HEALTH DIVISION ONPERYIT/SERVICES <br /> 445 N SAN JOAQUIN, p o box 2009, STOCKTON, CA 95201 <br /> FEE ;Mj0VENTDUE AMOUNT REMITTED CASH RECEIVED BYDATE PERMITNO. <br /> INFO <br /> EHt3,24Iriev.riM51 e_ a^ <br /> E1414,26 <br />