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APPL I CAT I ONS FOR PERM I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT EXPIRES 1Y FR M"DATE ISSUED <br />! (Complete in Triplicate) <br /> I <br /> Application is hereby madeto San Joaquin County for a permit to construct and/or install the work her described. This <br /> appiicatioa i made in caspiiance vith.8an Joaquin County Ordinance No. and 1862 and the Rules and Regt1�lations of Ban <br /> Joaquin Count Public HealNNthPry ices. <br />` I LIIV► 1City Lot Size/Acre <br /> Job Address h <br /> t 1 ] e l Q <br /> OAno' Nam I Ad res � u �• <br /> KSI1`lc��1,-�- ��X) <br /> es , �' !�D <br /> i for <br /> se No. Phone <br /> TYPE OF WELL/ I�: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Gl Out of Service dell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 <br /> DISTANCE TO NEAREST: SEP IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER-WELL PITS/SUMPS..— <br /> J. <br /> 1 <br /> INTEND`W_0SE k; �TY,PE-OF WELL,PROBLEM AREA—"CONSTRUCT90N-SPECIFICATIONS <br /> 0 I ustrial` ` ❑ Open Bottom C1-Manteca R Dia. of Well Excivation ' Dia. of Well CAsing <br /> mastic/Private ❑ G6vel Peck E-]Tracy Type,of Casing Specifications <br /> I'l Public 1-1 Other":. r rte,.'f (1 Delta Dep1Fi of Grout Seal Type <br /> of GrourM <br /> I I Irrigation .1 Approx, Depth I I E'stern—+ �� Surface Seal installed by Ih� <br /> Repair Work Done ❑ Type of Pump —o H•P a f-r State Work Don <br /> Well Destruction ❑ WeIII�Diamet <br /> Sealing Material i Depth <br /> . Y <br /> f Depth T ,:, --!'iller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I it REPAIR/ADDITION I I DESTRUCTION I ) Mo septic system permitted if:public sewer is <br /> �I <br /> available within 200 feet.) Ij <br /> { Installation will some: Ras'lce—{Commercial_ Other 41- <br /> Number of living units: - Number of bedrooms <br /> R <br /> y Character of&OR to a depth of 3 feet:r Water table depth <br /> SEPTIC TANK. O Type/Mig Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 1� r/ Method of Disposal p� <br /> ` Distance to nearest: Well .Foundation Property Line <br /> I �M <br /> LEACHING LINE L1 No.rS Length of lines Total length/size <br /> F FILTER BED D <br /> Distance to nearest: Well .Foundation Property Line <br /> SEEPAGE PITS II Depth Size ~' Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line w. <br /> DISPOSAL PONDS ❑ <br /> 7-- �— <br /> I hereby certify that I have prepaihred this application and that the work will be done in accordance with San Joaquin county or in -nces, 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 /> t employ any person in such manner as to become subject to workman's compensation laws of California." Contrectot's hiring or sub'i signature <br /> j certifies the following:"I rtify;�t at in the performance of the work for which this permit is issued, I shall employ persons subject to workman's componsa- <br /> i tion laws of California." u f <br /> The=appfitcytcall for rad i pact' ns. Cotplots drawin an r srse d <br /> o Date: <br /> Sig Ti <br /> I�IH� <br /> FOR DEPARTMENT USE ONLY I� <br /> Application Accepted by' Date.2 1fz Area I <br /> Pit or Grout lnspsction by u! Date Final Inspection by I� Dots G <br /> Additional Comments: <br /> I Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> RECEIVED 8Y DATE PERMIT NO. <br /> INFO CASH <br /> Er113-21IREV.IirSM P 11. L/ 7rTF <br /> Eli 14-M <br />