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APPLICATION FOR PERK[I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES .1 YEAR FR DATE I � <br /> -(Complete in Triplicate) n ` <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules mod Regulations of <br /> Joaquin County Public Health Services. } <br /> Job Address F`�/' /! City Lot Size/Acreage <br /> Owner's Name F Address / ! C <br /> '0 � Phone <br /> CaAd �� S { <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitor Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD; VF_ PROP. LINE A5-4 <br /> FOUNDATION <br /> "-- <br /> FOUNDATION r AGRICULTURE WELL OTHER WELL� PITS/SUMPS <br /> INTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationD Dia. of Well Casing <br /> 1.1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ T �C- _� Specifications <br /> Public fl Other 11 Delta Depth of Grout Seal 1DC1Type of Grout >f=../?at3r7� <br /> r 4� <br /> Irrigation �Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction: ❑ Well Diameter Sealing Naterial i Depth <br /> Depth �3i4 r Filler Material i Depth <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) r <br /> Installation will serve: Residence— Commercial— Other < <br /> Number of living units: Number of bedrooms s# ' <br /> Character of soil to i depth of 3 feet: —Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg tr)Capacity No. Compartments ' <br /> PKG. TREATMENT PLT,❑ Method of [)!Waal a° <br /> Distance to nearest: Well Foundation .Property Line <br /> f a, <br /> LEACHING LINE ❑ No. b Length of lines " Total length/size �� � A <br /> FILTER BED 0} -Distance to nearest: -Well FoVAdation Property Line <br /> --------------- <br /> SEEPAGE PITS + 11 Depth Size - - Numbers= <br /> SUMPS Cl Distance.to rtearesi'--�_Wall J bFo�daiiow '`Property Line <br /> DISPOSAL PONDS 0-t <br /> 1 hereby sonify that I have prepared this appliaaiion'and'that the work will be done r .accordance with San Joaquin county ordinances, state laws, and kl,rules and r ulations of the San Joaquin.:Coug—tt — } <br /> Home owner or licensed agent's signature oenifies the foilovring` l cbfy that in-thelperformance of the'work for which this permit is issued, I shall not <br /> employ any person in sucK manner as to become subjectito workman a compensation Iarv�i ffCaiifomia 'Contractor's hiring or Sub contracting signature ` <br /> certifies the following:"I certify tIG nn-tfrperfoiiftance of-th'e-work-far which this perNn[t Is'issued, I shall enAploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant us I regLrtf f td ctlons. Compleie drawing on reverse sipe. <br /> Signed X Date:, ��! <br /> Y <br /> NRT <br /> FOR DEPAMEN7•USE'O � <br /> I r- t ! 4 <br /> Application Accepted by L r t _ f — t —Date,1 2 Araa <br /> ' +�.. 3 F <br /> Pk or Grout Inspection by Date Final Inspection l Dat <br /> Additional Comments: : <br /> f <br /> Applicant - Return all cop to: San Joaquin County Public'Health Services i <br /> //��,,,��, T y !� Bnviionmen'tal Health Permit/services <br /> 67�u 7 445 N-Baa 'Joaquin;NP IO'Boz+2009, atkn, CA 95201 i <br /> IFEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br />' « EH 13-24'IREV."1Ix51 ' '�^" �"—/r.:.� �.�>:.n.. - _]�� �J�/'� t> l <br /> EH 11.26 vv ' OtJ LV <br /> !! f a <br />