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iy I� <br /> F - <br /> APPLICATION FOR PERMIT RECEIVED <br /> � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SHRVICES <br /> ENV IRON1d.SNTAL HEALTH DIVISION p 1992 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 ENV1R0NMLNTAL- HEALTll <br /> PERMIT/SERVICES <br /> I� <br /> REMIT EXPIRES 1 YEM FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby tsade'to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is teade in cotspliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health ices. .11 <br /> II <br /> Job Address City hot Size/Acreage <br /> rt <br /> Owner's Name Address <br /> Phone <br /> f I <br /> Contractor Address License No.��Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ns DESTRUCTION ❑ out of Service Yell <br /> PUMP INSTALLATION O SYSTEM REPAIR� OTHER D Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMI4S <br /> fINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� <br /> f I=1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing <br /> DomesticlPrivate L1Gravel Pack El Tracy Type of Casing_ Specificatbns I� <br /> i'1 Public n Other El Delta Depth of Grout Seal ' l yps of Grout 4 <br /> I I irrigation _.Approx. Depth I I Eastern Su ace Seal installed by <br /> Repair Work Done Ll Type'of Pump H P. ! r State Work Done <br /> ' f —Sealing Material i Depth <br /> ""'}"WeH-Destruction "'❑ 'Well Diameter- <br /> Depth 7Yller Material A Depth <br /> TYPE OF SEPTIC-WORK:—NEW-INSTALLATION.I L..REPAIR IADDITION I.I._DESTRUCTION I I INo seplic system permitted if public sewer is <br /> I available within 200 feet.) I. <br /> Installation wi11 terve: Residence Commercial_-_— Other t s <br /> Number of living units: Number of bedrooms -- -•---�- -�— } <br /> Character of soil to a depth of 3 feet: �~ f ! Water;Able depth <br /> SEPTIC TANK. ❑ Type/Mfgdapacity ) No. Compartments M <br /> PKG. TREATMENT PLT. ❑ ;; } Method of Disposal �M <br /> Distance to nearest: Well Found tion Property Line <br /> LEACHING LINE L1 No. 6 Length oflinesl Total length/size �M <br /> FILTER BED ❑ Distance to nearest: , Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number �pppM <br /> SUMPS Ll Distance to nearest: Well Foundation i r 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, stats laws, and <br /> rules and regulations of the San Joaquin County .11 <br /> r 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 /> I employ anT�L�lw <br /> such manner as to become subject to workman's compensation laws of California."Contractor's hinng.oi sub,Icontracting signature <br /> certifies th "I certify that in the performance of the work for which this permit;is issued,I shall employ persons subject to workman's compansa <br /> # tion laws ." I <br /> The appy ll for l req it inspections. mplete drawing on ev r side.I!'Sig� Title: Date: <br /> 'i FOR EP LATME USE ONLY <br /> II <br /> Application Accepted by I� Date ZZ �4rea <br /> Pit or Grout Inspection by Date Final inspection by °i� I� Date to 2 <br /> Additional Comments: <br /> Applicant - Return,-all copies to: San Joaquin County Public Health Services E <br /> Environmental Health Permit/services <br /> i; 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED C K H RECEIVE ;l3Y DATE PERMIT'NO. <br /> INFO i <br /> �• <br /> . EH11211REV.r/eb1 7 j 5/ <br /> EH t4•ffi <br />