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APPLI4ATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES t <br /> ENVIRONMENTAL .HEALTH DIVISION <br /> 445 N BAN JOAQUIN+ PHONE (209)488-3420 <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> MET EXPIRE YEJ. ROM D TE I SU 1 <br /> (Complete in Triplicate) t <br /> This <br /> e vith Ban Jue4uin County Ordinonce No. 549 end 1662 the Rules and It <br /> of San { <br /> Applicatiaa is hereby made,to Sea Joaquin County for a permit to construct and/or install the vortc herein deeti <br /> application is made in caamplian <br /> Joaquin County II Health is <br /> Lot Size/Acreage I. <br /> Cit � <br /> Job rest / <br /> Phone <br /> 5rraa ddress � /�Aw - (� <br /> '�V �/ 6` Phone <br /> ante No. <br /> ddr / flat of Service well C1 <br /> WELL REPLACEMENT ❑ DESTRUCTVON ❑ <br /> Monitoring <br /> OTHER ❑ onitoring Well [3• TYPE OWELL F WELL/PUMP: f SYSTEM REPAIR <br /> PUMP INSTALLATION ❑ <DISPOSAL FLO. PROP. LINE <br /> SEWER LINES r - <br /> DISTANCE T ���O NEAREST: SEPTIC TANK � AGRICULTURE WELL OTHER WELL�— <br /> PITS/SUMPS <br /> I FOUNDATION �— <br /> INTENDED USE TYPE OF WELL PROBLEM M AREA CONSTRUCTION'SPEC1kATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. o} Well Excavation i <br /> Ll I ustrial Type of Casing__ ' Specifications <br /> j * C] Tracy Type of tit <br /> sac/,Private ❑ Gravel Peck n Delta -Depth of Grout Seal <br /> .._, - ��, I'1 Other <br /> I"1 Public r I I stern .irf�ce Sea] lnstalled'by <br /> I I irrigation --Approx' 0e - —7`4 State Work Do <br /> of Pump H.P.-- <br /> flepair Work Done L3 Type Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter—_Zi_� biller Material i Depth <br /> Depth _ �: rmRted if public wet s <br /> available within 200 feet.l r <br /> TYPE OF SEPTIC WORK: NEW`INSTALIATION t.l REPAIfl/ADDITION i-1�DESTRUCT10N I I iNo septic system <br /> f <br /> Residence ' Com <br /> Other <br /> �installatio will serve: � mercial <br /> k Number of living units: Number of bedroomsr. Water table depth <br /> Charactef of soli to a depth of 3 feet: Capacity.,.— No. Compartments <br /> SEPTIC TANK. ,❑ Type/`Mfg R r _ 4 Method of Disposal <br /> PKG. TREATMENT PLT.Gl ,�`'. FProperty Lina��--- <br /> •- ell=Y oundation �-� <br /> Distance toJteare6t:- W <br /> - - <br /> i _ <br /> s Total length/size <br /> LEACHING LINE ❑ No. 3 Length of lines Property Line <br /> FILTER BED <br /> ❑ Distance to nearest: Wall Foundation <br /> Size Number <br /> SEEPAGE PITS 11 Depth Property Line—.�— <br /> LI Distance to nearest: Well FoundationProperty <br /> DISPOSAL PONDS ❑ <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 krws, end <br /> rules and regulations of the San Joaquin County a; „ <br /> Home owner or licensed agent's signature oertities the folfowin l certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any following;in such I c W that n the pe ancecot�he work for wh ccompensation <br /> this sperm yis issued,I sh s Temp employ pesos arsuhlact to worktman`scompensa <br /> certifies the ng `. <br /> tion laws of C nle." <br /> Th s is t st all t r Iti s. Com let drawing on r rse id <br /> Date:` <br /> Tit _.. _. <br /> g FOR DEPARTMENT USE ONLY _ Area / <br /> -� Date <br /> Application Accepted by i Date <br /> ► Pit or Grout Inspection by Date Final inspection by <br /> _ ---- <br /> Additional Comments: lCounty <br /> Applicant - Return all Copies to: Environment l Healthublic Permit/ Serviceealth s ices <br /> . ,445 N Ban-Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> K RECEIVED BY DATE PERMIT'N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO _ /� <br /> . SH M24 tRtV. V <br /> EH 1476 <br />