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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH .DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> p O BO% 2009, STOCKTON, CA 95201 <br /> PERMIT ESPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <br /> t <br /> ma •� <br /> Application is hereby dJto San Joaquin County for a permit to construct and/or install the work herein describedr <br /> application is made in comitance with San Joaquin County Ordinance No. 5k9 and 1862 grid the Rules and Regulation San <br /> Joaquin county Public Health Services. I /� Y t <br /> J 1 S0 � e, `T� City i4cpze/Acreage " <br /> ,Job Address it a <br /> -�- Phone <br /> S <br /> OwnerAddress's Name � -� ` ,..y <br /> - ' W - <br /> _ _ -icense-No. _ C-Phone- <br /> _ <br /> Contractor � ress�_ '--•-=-�- <br /> TYPE FF—WE LL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION Cl Out of Service well <br /> OTHER p Monitoring Well <br /> PUMP INSTALLATION E3SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �- AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> PITS/SUMPS <br /> USETYPE OF WELL _PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia.of Well Casing <br /> CI Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation <br /> Type of Casing_ Specifications <br /> f.l Domestic!Private ❑ Gr ave/ Pack L7 Tracy Depth of Grout Seal Type of Grout f <br /> i'1 Public <br /> (-I Other (-1 Delta <br /> I I Irrivation M Approx. Depth l I Eastern Surface Seal Installed by T {[ <br /> Ii H P __ State Work Done v <br /> Repair Work-Done 0 -Typo of Pump- _ — <br /> Sealing Material 8 Depth <br /> Well Destruction ❑ Well Diameter Filler Material & Depth {n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITIr1N <br /> AUCTION I I (No <br /> {within 2Op f�ett}ed if public sower is <br /> �r <br /> ' Installation will serve: Residence Commercial char / f►+ 1 <br /> Number of living units: Number of bedrooms <br /> Character Water table depth <br /> er of soil to a depth iof 3 tees: <br /> SEPTIC TANK. E) TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, ❑ I� � ;.-.. Mett►'od dC Dispdsal <br /> Distance to nearest: Well Foundation Property LLiinne_ <br /> -�--Totp I length/size v <br /> LEACHING LINE Length of lines y / <br /> FILTER BED [l Distance to nearest: Nell — Foundatiari -ProparTy.Line <br /> E OSAL'PON.DS ❑ `� <br /> -Size h -Number <br /> bet <br /> SEEPAGE PITS.-' I^ Depth S, h n <br /> lanca to nearest: Well Foundatio — Porty ne <br /> SUMPS � r <br /> DISI <br /> r <br /> - <br /> 1-hereby certify.that I have prepared this application and that the woik-will;be done in accordance with-San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county <br /> "I certify that in the performance of the work for which this permit is issued, l shall not <br /> Home owner or licensed agent's signature certifies the following; <br /> Ii 'employ any person in such manner as to become su6jeci to`w`orkman's compensation tiiws of California-"'Contradtor's`hiring'arsut>contracting tdgnature- <br /> certifies the following: "I Certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tiZapplics <br /> of California." <br /> Tt call f ,r tli IiI req iced i pec S. I drawing a reverse side. <br /> S Title: Date: <br /> FOR DEPARTMENT USE ONLY C 9 <br /> # Application Accepted by - <br /> Date la <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Returnlall copies to. San Joaquin County Public Health Services <br /> E ` Environmental Health Permit/Services <br /> I I 445 N San Joaquin, P C Box 2009, Stkn, CA 95201 <br /> FEE I CK RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT.REMITTED CASH <br /> . EH 13.241REV,r/MS)C <br /> 6 <br /> k _ EH 141nC.J <br />