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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HM�SIONRVICES ' <br /> ENVIRONMENTAL HEALTH <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> i ` <br /> PERMIT EXPIRES "i 'YEAR FROM DATE ISSUM <br /> (Complete in Triplicate) <br /> 9 <br /> to San Joaquin County for a Permit to construct and/or install the work herein described. <br /> Application is hereby made This <br /> Application is here in cctqmade <br /> to <br /> with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulati ns of Elan <br /> Joaquin County Public Health Services. Jl <br /> LoL'Size/A <br /> City creage !�[ <br /> Job Address J <br /> !Phone <br /> Owner's Name A dres <br /> i. r, <br /> -1 <br /> d �icense Phone <br /> Contractor <br /> ress I�kr>� <br /> TYPE OF Wof service we.Lj. L1 <br /> ELLIP MP: I� NEW ELL © WELL REPLACEMENT ❑ DESTR OTHfR❑ Out Monitoring Well. Q <br /> PUMPi INSTALLATION ❑ SYSTEM REPAIR El DISTANCE TO NEAREST: SEPTIC TANK ��� <br /> SEWER LINES ��-- DISPOSAL FLO. � PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER.WELL PITS/SUMPS <br /> INTENDED USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Specifications - <br /> b: Type of Casing_ <br /> Cl DomesticlPrivate ❑ Gravel Pack C1 Tracy <br /> Depth of Grout Seal Type of Grout <br /> 1'1 Public CI Othi,ier C1 Delta "i I. y' <br /> I I Irrigation <br /> Apprax. Depth I I Eastern Surface'Seal Installed by <br /> State Work Done <br /> Repair Work Done 0 Type tf Pump H P <br /> r <br /> 'Sealing Niaterial i Depth <br /> WoU Destruction ❑ Well Diameterth <br /> Depth <br /> hiller Material ,. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR1ADOITION l DESTRUCTION I 1 alvailabPahc system w Thin 200 feet.) if public sewer is <br /> k Installation will serve: Reside nt}0 Commercial�r Other , t <br /> Number of living units: Number of bedrooms t <br /> Character of sod to a depth of 3 feet: Y <br /> Water table depth <br /> SEPTIC TANK ❑ T lliilif9 Capacity— No. Compartments <br /> -..r Method of Disposal <br /> PKG. TREATMENT PLT.Q I� � Property Line i <br /> Distance to nearest: Well Foundation <br /> It <br /> Total length/size <br /> LEACHING LINE ❑ No6Length of lines <br /> y ' eng - 7, <br /> ❑ Distance to nearest. Wall Foundation =-- Property <br /> FILTER BED <br /> 4 �'+ <br /> 4 Number I <br /> ' SEEPAGE PIT l l D�Pth <br /> Size , <br /> SUMPS CI D`istance to newest:. Well 1Y i!- Foundation T2 - - Property Line <br /> DISPOSAL PONDS ❑ �I <br /> 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 i <br /> Homs owner or licensed agent' signature certifies the following: "I certify that in the performance of the work for which this permit is issued, (shall not <br /> employ any person in such manner as lo-become subject.to-workman's-compensation laws of California."Contractor's hiring of sub-cont signature <br /> certifies the foltoowing:"I cartity: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.,, u <br /> The applica N r ell `` it Inspaation C plata drawing on revs side. <br /> S ned �I. Title: Date: <br /> 4WI/J_ <br /> F DEPARTMENT USE ONLY I�1 0.Z t° Area <br /> - Dais <br /> Application Accepted by } I <br /> Date 7i + Final Inspection by Date <br /> �2 <br /> Pito Grout Inspection by 4 t h <br /> A <br /> Additional Comments: <br /> f <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health permit/Services I <br /> 445 N San Joaquin, P O Box 2009, Sttn, CA 95201 <br /> CK PERMIT'N0. <br /> 4 FEE AMOLINT'DUE AMOUNT REMITTED CASH <br /> RECEIVED$Y GATE <br /> INFO <br /> . EH13.24OW,$1651 <br /> EH 14.76 I <br />