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,t — — --•cam----ssw-•T-_"_:�� ��. _ <br /> F <br /> i <br /> j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUPHONE (209)468-3420 <br /> P O BOX—ko , W CKTON, CA 95201 <br /> PERMIT F$pIRES 1 YEAR FROM DATE ISSUED <br /> it (Complete in Triplicate) <br /> Thi <br /> application i9 hmadebin compliance withuin SanGounty Joaquinor untyrmit to Ordinancenstruct No. 5498andp1862sand1�he Rule s herein dRegulationsdof Sans <br /> PP �S <br /> Joaquin County Public Health Sery ces. <br /> I CO r� City t Size/Acreage <br /> Job Address 11 0 11s � <br /> Phone <br /> dress <br /> Owner's Name / <br /> i Contractor t��♦ dress • <br /> License No.�Phone n <br /> INEW LL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI out of Service Well ❑ <br /> TYPE OF WELL/PUMP. OTHER 0 Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation N �Dia. of Well Casing <br /> n Industrial 0 Open Bottom C1 Manteca [specitications— <br /> Ca Domestic/Private ❑ Gravel Pack C7 Tracy Type of Casing_Depth of Grout Seal TYPe of Grout <br /> {'1 Public 1-1 Other fl Delta <br /> 5�daca Seal Installed by <br /> I I irrigation Apprax. Oept��' lI,Easrern S ;�O� <br /> r of Pump H.P. State Work Done ``�►`1 <br /> Repair Work Done TYpe Sealing Material & Depth ` r <br /> Well Destruction ❑ Well Diameter <br /> Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I availatilelwithin 200 feetsystem r'le� rcsewer is <br /> Installation will serve: Residence— Comm is[ Other <br /> Number of living units: Number of bedr ms Water fable depth <br /> Character of soil to a depth of 3 feet: ffn:Compartments <br /> SEPTIC TANK. ❑ Type/Mfg IN <br /> Cap rty <br /> r__� <br /> ethod of Disposal <br /> PKC. TREATMENT PLT. ❑ Fo ation� � Prk, <br /> Line <br /> Distance to nearest: Well <br /> t _ <br /> Totalylbngth/Iiia, <br /> LEACHING LINE ❑ No. & Length of lines ' - I //- Line <br /> FILTER BED ❑ Distance to nearest: Well oundation _ 1 Y1 <br /> SEEPAGE PITS 11 Depth <br /> Site �Nktf'nbet`'� <br /> SUMPS Ll Distance to nearest: W Foundatio ffP•aa operty�Line <br /> DISPOSAL PONDS ❑ r, <br /> 1 i hereby certify that I have prepared this application nd that the work will be done in acc rda�cetJhaJoaquin county ordinances, slate laws, and <br /> rules and regulatio the an Joaquin Count �f <br /> Home owner or • ensed age is signature certifi the following: "I certify that in the performs er_o w rk for which this permit is issued, l shall not <br /> employ any eon in such nner as to bac me subja t workman's compensation laws of Cilli n4 Cont'ractoi s hiring or sub-contracting signature <br /> eertilies the Mowing: "I t if that in the o e e the work for which this permit is issuerd, I s I!employ persona subject to workman's compensa• <br /> tion laws of Californ <br /> L <br /> The applic nt must f II r r n Complete draw n ide. .�� <br /> � <br /> Title: ..r w Date: <br /> Sign <br /> �x <br /> t FOR DEPARTMENT USE ONLY <br /> Da e Area <br /> Date Final Inspection y <br /> Application Accepted by F� Data <br /> 0� <br /> Pit or Grout Inspection by <br /> �— & *; � �U <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services N <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin P O Box 2009, StRn, CA 95201 `jUl <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> FO AN <br /> . En 13-24 IREV,t r h <br /> EH 11.1E <br /> k <br />