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n Q <br /> APPLICATION FOR PERMIT �✓✓.� <br /> SAN JOAQUIN COUNTY 'PUBLIC HEALTH SERVICES [j0 Q,.L <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O 13O% 2009, STOCKTON, CA 95201 NOW <br /> (209) 468-344-7,3tk* <br /> PERMIT ES.P,IRSS 1 MAR ZROM DATE iSSUM <br /> (Complete is Triplicate) k <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This G <br /> application is made in eortipllance with San Joaquin County Ordinance No.- 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address A93 q /"Ves� <br /> 6j city <br /> _ Lot Size/Acreage <br /> Owner's Name61 OK6 � /) 7 Address 4JPhone <br /> �� I! <br /> Contractor � •' Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service ll Cl { <br /> P ALLATION C7 SYSTEM REPAIR 0 OTHER ❑ blonl ng Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. . INE <br /> FOUNDATION A TUBE WELL OTHER WEL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON TIONCATIONS t <br /> 0 Industrial - ❑ Opan_Bottom._.rF, .© Manteca Dia. of xca "- Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack C7 Tracy a Of Casing Specifications <br /> * Public CI Other ❑ Delta Depth of Grout Seal Type of Grout <br /> GI Irnpation _ . Approx. Depth tern Surface Saul Installed by a <br /> Repair Work Done U Type of Pum - H.P. State Work'Done'_ <br /> Well Destruction ❑ We ter, Sealing Material i Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ RE t�ITTUIA(Nq septic system permitled if public sewer is <br /> a t 'n 200 feet.) <br /> Installation will serve: Residence - Commercial�, Otfte .___ <br /> E <br /> Number of living units: Number of.bedrooms .�ft mai, If��� � i��� �� <br /> Character of soil to a depth of 3 feet: ,- lrlI f (+ gr table depth <br /> SEPTIC TANK © Type/Mfg .� -----—��n u�� r X14%&mpartments <br /> . . L1 <br /> PKG. TREATMENT PLT. 0 � i by ivironm 4�1- 9¢ ��}}fr44;;. Method of Disposal <br /> t ! Heaith "Pr6W�A�ine <br /> Distance to nearest: Well Foundation <br /> f <br /> LEACHING LINE Cl No, 8 Length of lines Total Iengthlsize <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Silo Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line € <br /> DISPOSAL PONDS ❑ <br /> a <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 d <br /> rules and ragufations of the San Joaquin County f <br /> Home owner or licensed agent's signature certifies the fallowing: "I carlify 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 following; "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 /> The applicantr�mut all for 1 required inspections. Complete drawing on reverse side. <br /> 5ignad Q Title: — � � Date: O 2--mm rZ <br /> R PARTMEN7 USE ONLY <br /> Application Accepted by A A Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES o <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEEtt <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK IT-1 RECEIVED BY DATE J PERMIT NO. <br /> . EK 13.24[REV,1)"5) �U tqoo +� of <br /> fk 74.28 ��� 063,1 <br />