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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> p 0 BOX 2009, STOCKTON, CA 95201. <br /> (209) 468-3447 <br /> R <br /> (Complete in Triplicate) <br /> in <br /> Application is hereby made,toanan Joaquin <br /> county for <br /> Goa pe mit ordinance cenNoru51+9ct &and�1f362sand thetaU eRulee aadwork eRel3ulationsdOf Sans <br /> applicatioq is made in cotii� <br />' Joaquin County Public Health Services. <br /> Job Address �. gig <br /> AA/�E L City . Lot Size/Acreage %O 3�� �'�� <br /> L-dflil E S 77,'•) Phone -1-2-0 7/r <br /> k <br /> Owner's Name <br /> �Z_ L Address — <br /> F 7�-"7� Phone f 397/ <br /> G OO-Dn Address DEQ License No. <br /> Contractor F -. ; <br /> NEW WELL ❑ WELL REP —Well 0 <br /> LACEMENT F7 DESTpUCTION ❑ Out of Service Well t TYPE OF WELL/PUMP: OTHER ❑ Monitoring <br /> ,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> IF SEWER LINES - DISPOSAL FLD, PROP. LINE <br /> r DISTANCE TO NEAREST: SEPTIC.TANK —���-- AGRICULTURE WELL OTHER WELL PITS/ <br /> SUMPS <br /> FOUNDATION — <br /> YPE OF WELL PROBLEM AREA--CONSTRUCTION SPECIFICATIONS - - <br /> INTENDED USE T: � Dia. of Well Casing <br /> r n industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation <br /> t- > Type of Casing Specifications <br /> - <br /> U Domestic/Private C1,.Gravel Pack C7 Tracy Type of Grout <br /> I'I Other t ❑ Delta Depth of Grout Seal <br /> IO Public ii <br /> D Irrigstion 1L Approx. Depth ❑ Eastern Surface Seal Installed by <br /> H p State Work Done <br /> Repair Work Done U Type of Pump Sealing Material i Depth <br /> Weil Destruction D Weil Diameter <br /> 0i Filler Material i Depth <br /> De0th No soPti system <br /> TYPE OF SEPTIC WORK; NEW iNSTALL.ATION " REPAIRIADOITION Ll DESTRUCTION U availabe within 200 feetltjed if public sow <br /> er is <br /> /' Oxyyl M U"i11 1�'y <br /> Installation will serve: Rsspencs °� Cainmercial the( <br /> Number of living units: Number of'bedrooms <br /> y Water table depth <br /> Character of&oil to a depthof3 feet: _ LA f LpO No. Compartments <br /> SEPTIC TANK 0 I Type/Mfg r -If ----- Capacity�— <br /> PKG. TREATMENT PLT. D -" �" �" - T Method of,Disposal <br /> A� a Foundation r ' <br /> Distance to nearest; WeII �^ Property Line <br /> • n. <br /> !e O length/sizeLEACHING LINE No. & Length of linesi <br /> FILTER BED FI Distance to nearest: Welt Foundation Property Line <br /> { 2 Number -3 <br /> SEEPAGE PITS l Depth Size i <br /> SUMPS .. _ LI Distance to nearest: Well 8L 1A. Foundation !BD L__ Property Line. - <br /> DISPOSAL PONDS't„'D-.' <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.._ <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 become 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, l shall employ persons subject to workman's compenss <br /> tion laws o1 California." I�I <br /> The applicant must It for all required inspections. Complete drawing on reverse side. <br /> Signed X_rJ I _ Title: Date: `fir <br /> FOR DEPARTMENT USE ONLY <br /> r I ! [ Area <br /> Application Accepted by �- • Date `O <br /> Date Final inspection by Date <br /> f l <br /> Pit or Grout Inspection by II <br /> Additional Comments: <br /> Applicant - Return a.l.l ,copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ii ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2049, STOCKTON, CA 95201 <br /> FEE I CK RECEIVED BY DATE PERMIT NO. <br /> INfO AMOUNT DUE AMOUNT REMITTED CASH <br /> . EH 19.24 inEv.i/hSl ��1 -- 7 <br /> EH',4,M <br />