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s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O 13O% 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I <br /> (Complete in Triplicate) <br /> -her <br /> in <br /> vork <br /> application le biadebincaaatpliannce vithJoaquin <br /> SanCounty <br /> Joaquinfor <br /> County ordirmit nanceconstruct <br /> no. 549and/or <br /> 1862install <br /> and the Rules andeRegulstionsdof Sans <br /> application 1 <br /> Joaquin County Public Health Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> w S0 IQ Phone <br />` Owner's Name <br /> 1 License No. 35 Phone73 <br /> Contractor ' �` "'�ss+�Address Q <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL RE LACEMENT n DESTRUCTION Out of Service Well ❑ <br />` PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> OTHER ❑ Monitoring Well ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK �— <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> " INTfNDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> e�C} Industrial ❑ Open Bottom ❑ Manteca Die. 01 Well Excavation Specifications <br /> L) Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> I:1 Other n Delta" Depth of Grout Seal Type of Grout <br /> I'l Public ,1 <br /> f <br /> I I Irrigation �Approxi Depth I I Eastern Surface Seal Installed by ` [✓ <br /> State Work Done <br /> Repair Work Done U Type of Pump H.P. t! <br /> Sealing Material i Depth Q- <br /> Well Destruction O Well Diameter Tiller Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I iNo available lc system wthin 20feet.I if public sewer is <br /> i <br /> Installation will serve: Residence— Commercial Other : <br /> 4 Number of living units: Number of bedrooms Water table depth <br /> l Character of sell to a depth of 3 feet: <br /> SEPTIC TANK ❑ Typo/Mfg Capacity_ No. Compartments <br /> PKG. TREATMENT PLT. Cl Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE L1 No. 6 Length of lines Total length/size /t <br /> f FILTER BED ❑ Distance to nearest: Well Foundation Property Line (! <br /> SEEPAGE PITS I ] Depth Size Number <br /> k <br /> _ SUMPS LI Distance to nearest: Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <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 fallowing.'•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." <br /> l The applicant must pWfor r*qV inspections. Complete drawing on reverse side. <br /> Signed X� <br /> Title:I — Date: <br /> � F DEPARTMENT�SIENLY <br /> Date � I <br /> Application Accepted by 4k—�-Ares <br /> Pit or Grout Inspection by <br /> Pate Final inspection by �'` Date Z� <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin,County Public Health Services <br /> Environmental Health Permit/Servicers <br /> { 445 N San Joaquin, P ox"2009, Stkn, CA 95201 <br /> FEE AMOUNT{1lIE AMOUNT REMITTED Kff RECEIVED BY ATE PERMITNO. <br /> INFO <br /> . Eµ13-24 MEV,fins) W d.Cy K=> // <br /> EH 14.78 <br />