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-a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQU IN COUNTY PUBLIC HEALTH SERV I CES P�4�f ll`I �� , <br /> ENVIRONMENTAL HEALTH DIVISION /� � <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 #'®ECEI dd n <br /> P O BOX 2009, STOCKTON, CA 95201 MAY 14 19L� <br /> PERMIT EXPIRES 1 1 FR M DATE ISSUED SAN JOAQQIN CD 1=,Tv <br /> (Complete in Triplicate) PUBLIC HEAI-THSF'4- <br /> ENVIRONMENTAL HEALIti <br /> ` .ENVIRONMENTALHEALIti Ui�I 1v <br /> Application is hereby made to &mJoaquin county for a permit to construct and/or install the work herein described. This <br /> 4 and 1862 and the Rules and Regulations of San <br /> application is made in compliance with San Joaquin County Ordinance No. 51+ <br /> Joaquin County Public Health Services. <br /> SCity Lot Size/Acreage <br /> Job Address '. <br /> Owner's Name <br /> Address Phone <br /> Contractor <br /> (J1 l Address License No. Phone <br /> TYPE OF WELWell El <br /> L _ NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out Monitoring Well C7 <br /> PL,MP INSTALLATION ❑ SYSTEM REPAIR KDISPOSAL <br /> OTHER ❑ <br /> ` SEWER LINES FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ,. <br /> INTENDED USE' TYPE OF WELL._ ,PROBLEM AREA_CON TION_ONSTRUCSPECIFICATIONS <br /> L-1 Industrial ❑ Open Bottom © Manteca Dia. of Weil Excavation <br /> + Dia. of Well Casing I <br /> T of Casin Specifications - <br /> Domestic/Private ❑ Gravel Pack L� Tracy _Y�_� <br /> Public I'1 Other l-"1 Delta Depth of Grout Seal' ype of Grout <br /> I I Irrigation —Approx.,Depth I I Eastern Surface Seal Installel by <br /> Repair Work Done U Type of Pump H.P. _ _1 State Work pone <br /> Soiling Materiel i Depth I <br /> Well Destruction O , Well Diameter ' f Pi -leiHits" Depth r <br /> Depth I ' - - 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I R PAIRIADDITION 1 I DESTRUCTiON'f 1`ava�s�P�i �h�n 20p f permitted if public sower is v} <br /> Installation vviif servo: Residence Commercial-L Other r <br /> Number of living units: Number of bedrooms - <br /> '.'A~ tJ <br /> Chaept <br /> Character of ooh to s dh of 3 feet: � { Water table depth <br /> SEPTIC TANK ❑ Type/Mfg, --' Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT.© f k-i <br /> Durance to nearest: Well Foundation Property Lina r ,t <br /> LEACHING LINE ❑ No. a Length of lines Total length/size <br /> 6 FILTER BED ❑ Distance to newest: Well Foundafian" Property <br /> SEEPAGE PITS I I beplh- Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS' ❑ r: <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 perac in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> + certifies t :"I certify that in the performance of the work for which this permit is issued,I shall em loy persons subject to workman's eompenss <br /> f tion of Cal' mla." } <br /> The appy i call for ailsqu inspect' s. C plete drawing on side. , <br /> 1 <br /> Title: Dite: <br /> Signed <br /> ? FOR DEPARTME USE ONLY <br /> Application Accepted by <br /> j Date � � � Area <br /> C" ate Final Inspection by Deta 7 <br /> Pit or Grout Inspection by r, <br /> t � - <br /> Additional Comments: i <br /> i Applicant - Return all copies to: San Joaquin County Public Health Services <br /> j Environmental Health Permit/Services <br /> ' f 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> 1 <br /> FEE AMOUNT DtlE AMOUNT REMITTED A CEIVE BY O E PERMIT'NO. <br /> INFO <br /> . EH 13.24IREV.1/01W <br /> EH 14.26 fff <br /> t <br />