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APPLICATION FOR PERMIT ! <br /> JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> AYW8NENVIRON1lENTAL HEALTH DIVISION <br /> RECMVgPC0 BOX 2009, STOCSTON", CA 95201 <br /> S 0982 (209) 468-3447 <br /> SAN JOAQUIN CC Y R <br /> PUBLIC HEALTH SE-VICES (Complete in Triplicate) � <br /> ENVIRONMENT,g L i I l F rile,:, <br /> Application is heresy made, , Srib`ddaq�t�l '!&o Mty for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin county, Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Size/Acreage <br /> Job Address city of <br /> r Phone <br /> Owner's Na .Address <br /> tT � �' s <br /> re ✓AL9Cetise No. Phon <br /> Contras DESTRUCTION ❑ out of Service well ❑ <br /> TYPE OF WELL/PUMP'. w NEW WELL ❑ _ '��_ * <br /> WELL REPLACEMENT C] to <br /> Well <br /> �� ? <br /> PUMP INSTALLATION Zoo <br /> SYSTEM REPAIR OTHER ❑ <br /> SEWER LINES ���____-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL <br /> �— PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> al ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationSpecifications <br /> fl in <br /> in <br /> Type of Casing omesticlPrivate Cl Gravel Pack C7.Tracy � Depth of Grout Seal Type of Grout <br /> M Public I1 Other. ❑ Delta <br /> U Irrigation `:Appr0x,`-De`pth 4 Easte_rn, ' Surface Seal installed by <br /> J�_ H P State Work Done <br /> Repair Work Done 0 tYPe of Pump L Staling Material i Depth <br /> j Well Destruction © Well Diameter; SeI` <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK:., NEW1NST-ALLATION D REPAIR/ADDITION LT DESTRUCTION afvailablerwthin 200 feec system t.) it public sewer is <br /> I[l Installation will serve: JReside6cs Commercial Other <br /> Number of living units: - ... —Number of bedroom$ Water table depth <br /> Character of soil to a depth of 3 feet: c <br /> [[ Gapacity�-- No. Compartments <br /> SEPTIC TANK ❑ TypelMfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well foundation- - Property Line <br /> LEACHING LINE 0 No. & Length of lines ,.Total length/sire <br /> F FILTER BED Cl 'Distance to nearest: W9It Foundation ` <br /> 2Property Line <br /> SEEPAGE PITS 11 Depth _ Size Number <br /> } SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> I hereby sonify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Taws, an <br /> rules and regulations of the San Joaquin County <br /> k 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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signatur <br /> i certifies the following: "I certify 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." q <br /> The applicant mus for all required ' spections. Complete drawing on r rse nide: <br /> t <br /> Title: s�e - — Date: <br /> Signed 6 <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> t <br /> Pit or Grout inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> I Applicant - Return all copies to: EN <br /> ENVIRONMENJOAQUIN TAL HEALTH-DIVISION HEALTHUNTY PUBLIC PERMiT/SERVICES <br /> 445,_N,SAN JOAQUIN, P 0 BOX 2049, STOCKTON, CA 95201 <br /> 6 FEE Cx RECEIVED BY DATE PERMIT'NO. <br /> 1 INFO AMOUNT DUE AMOUNT REMITTED <br /> , EHu-24IREV,i/AW yC' �,�=[r0 0-04I �' —3/2-5 <br /> EH"cas <br />