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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONNMTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> ` T <br /> (Complete in Triplicate) <br /> tall <br /> work <br /> in <br /> ppis hherebin made cornpllance withuSan in CJoaquin ounty ocounr a ty ordinance rmit to nNo. 549struct 8and o1862sand the eRules and Regulations dof Sans <br /> application <br /> Joaquin County Public Health 8ervicea. <br /> City r, d9 Lot Size/Acreage <br /> Job Address 9r/ <br /> Phone .� G <br /> Owner's Name A C l Address <br /> � GnrgStyuay�iro/1 D <br /> �. Address 3 ►+�' Incense No.�`�•�?9f�Phone 57 <br /> Contractor DESTRUCTION ❑ Out of Service Well Cl <br /> TYPE OF WELLlPUMP. NEW WELL ❑ WELL REPLACEMENT ❑ Monitoring Well <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES DISPOSAL FLD, PROP: LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PR09LT EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom CJManteca Dia. of Well Excavation <br /> "'n Type of Casing Specifications <br /> w omestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Tvpe of Grout <br /> [O Public <br /> is Other ❑ Delta <br /> CJ IrriUation —.Approx. Depth 0 Eastern Surface Seal installed by <br /> f H.P. _� ------ State Work Done <br /> Repair Work Dona U Type of Pump r� Sealing Materia & Depth <br /> Well Destruction ❑ Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTic WORK: NEW INSTALLATION Cl .REPAIR1ADOiTION Ll DE57RUCTIQN CAavailableNo rwit in 200 feet.) if public sower is <br /> Installation will serve: Residence Commercial— Other <br /> i Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK © Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line - <br /> f LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED I:1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS <br /> at the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and th <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 subcontracting signature <br /> certifies the following: 111 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> lion Iowa of California." <br /> The applicant 11 for all re its ins ctions. Complete drawing on reverse side: <br /> Signed Title: <br /> Date: <br /> FOR DEPA TMENT USE ONLY <br /> Dote Area <br /> Applicetlan coapted by - <br /> Date.�__-- Final Inspection by Dato <br /> Pit or Grout Inspection by ' <br /> Additional Comments: <br /> Applicant - Return all copies to: SAP[ JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE CK RECEIVED BY PATE PERMIT N0. <br /> INFO AMOUNT REMITTED CASH i {� <br /> . EH 13-24 INtty.irn61 4�3-s �c �� L <br /> EH 114.26 <br />