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IV . APPLICATION FOR PERMIT <br /> `- - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 F, �i� ✓ ; <br /> (209) 468-3447 <br /> P BK T 9MIRES 1 YEAR PROM DATE I.SSLIM ����#" �'�'+` ���� �`� :• <br /> (Complete in Triplicate) `d�,1,C.. <br /> made to San Joaquin County for a permit to construct and/or install the work herein descri�>ed t-T h <br /> Application is hereby is, <br /> applioatian is made in comopllance with Ban Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulstione of,�t3an ,l <br /> Joaquin County Pu is Health Services. <br /> 8 I <br /> Job Address 'Cit Lot Size/Acreage i <br /> r <br /> dPhone <br /> OwnerNam, <br /> Nem <br /> Address <br /> IRC aV+' iak-4ss "; " rY i License No. Phone <br /> TYPE OF WELL/PUMP: NEW W •Cl 'r WELL REPLACEMENT n- DEST UCTION ❑ out of Service we11 CT <br /> PUMP INSYAI:i:AT10 ,,, <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 0 <br /> .� . <br /> "DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLU. PROP, LIN <br /> _- _::�i.r„"FOUNDATION -- `AGRICULTURE WELL.�` ` .OTHER.WELL.— /SUMPS <br /> INTENDED USE"" " TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial _ f ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private C1=Gravel Pack ❑ Tracy " Type of Casing Specifications w-)m4c,,) <br /> �iblic 'i'1 pthe+ ❑ Delta F Depth of Grout Seal Type of Grout <br /> -�--- SG Irrigation �..ApproK. De th =ern ace Serjl knstalled bRepair Work Done C3 "Type of Pum iOIL <br /> Sealing Material i Depthpol -H <br /> Well Destruction ©. Wer6il t r <br /> Depth Filler Material i Depth <br /> TYPE.OF SEPTIC WORK; NEW INSTALLATION❑ REPAIRIADDITION M DESTRUCTION G 1No septic system permitted if public sower is <br /> r, available within 200 feet.) (� <br /> ,Installation will serve: ""Residence..— Commercial_„_. Other <br /> Number of living units: Number of bedrooms a <br /> Character of soil to a depth;of 3 feet: Water table depth ,n <br /> 16 SEPTIC TANK ❑ .Type/Mfg Capacity No. Compartments �J <br /> F Disposal <br /> Di <br /> d hosp <br /> Method PKG. TREATMENT PLT. Ci ? nI1 <br /> Distance to nearest: Well -----,.;--Foundation Property Line 1 <br /> r <br /> r`. <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size ^ <br /> FILTER BED Cl Distance to nearest: Well t Foundation Property Line ,l <br /> SEEPAGE PITS I I Depth Site Number <br /> SUMPS LI Distance to nearest: Well -Foundation Property Lina <br /> __ ,.. _ _ _ ,.�.. �. _ <br /> `DISPOSAL PONDS ..w❑•,..:;�,,..-.w ,-�� ;�"�.. �-�..=�-:..'�.-�-•--.��..�—� <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, andY <br /> rules and regulations of the San Joaquin County <br /> k Home owner or licensed agentis 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: "I cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa• <br /> tion law I olifo a•" <br /> kf The app) 11 f r,all required inspections. Complete drawing o verse si <br /> Si ned <br /> Date. <br /> K-DEPARTMENT USE I Ni.- ,,t _ <br /> Application Accepted by PIZ DatedZIZ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 4 Additional Comments: <br /> Applicant « Return all copies to. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEEKE <br /> AMOUNT DUE AMOUNT REMITTED G <br /> INFO ASH RECEIVED BY DATE PERMIT'NO. <br /> /�� ,p <br /> . EH13.24MEv,,ih5) ?bfi�v -/✓�GiI G� 1. 1-16 CA1 y <br /> -Nal <br /> fM 7 .26 <br />