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9 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRON![ENTAL HEALTH DIVISION ! <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 C <br /> p O BOX 2009, STOCKTON, CA 95201 <br /> i <br /> PERMIT aPIRES YE FROM D T'E I S <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This r <br /> application in made in compliance with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San_ <br /> Joaquin County Public Health Services. <br /> r /, /� /' Lot Size/Acreage <br /> Job Address � + <br /> f' /[J //9 / City <br /> ,5 Phone <br /> Owner's Name <br /> - A ddress I J <br /> .. -�. Address License No. <br /> —phone �3 <br /> Contractor <br /> W WELL REPLACEMENT ❑ DESTRUCTION ❑ out or <br /> TYPE OF WELLIPUMP: NEWELL D Monitoring Well C]PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mn <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONAGRICULTURE WELL OTHER WELL PiT5/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Excavation Dia. of Well Casing <br /> n Industrial © Open Bottom LJ Manteca Specifications Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ <br /> I'1 Public Cl Other <br /> F1 Delta Depth of Grout Seal _ Type of Grout <br /> I l Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> H P ; State Work Done <br /> Repair Work Done L] Type of Pump Sealing Material i Depth (n <br /> Well Destruction 0 Well Diameter hiller Material fe Depth vt <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION DESTRUCTION I I alvailablelwit in 200 c system jeett�ed'+f public sewer is <br /> Installation will serve: Residence, ✓/Cornmercial Other — <br /> Number of living units: Number of bedrooms ` <br /> Water table depth <br /> Character of soG to a depth of 3 teat: No. Compartments <br /> SEPTIC TANK- O Type/Mfg Capacity <br /> �, Method of Disposal <br /> PKG. TRf/1TMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LL—No. Total length/size f <br /> No. 8 Length o} lines <br /> FILTER BED Cl Distance to nearest: Well" 'CO..r t Foundation <br /> r Property Line r r <br /> SEEPAGE PITS ICY'Depth 1 ' Si:e L° Number <br /> SUMPS L1 Distance to nearest: Well + �Foundation Property Line <br /> tl , •� <br /> DISPOSAL PONDS ❑ <br /> ion and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this applicat <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 person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is isiued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." �. . <br /> r <br /> 1 The applica mus all for all requir in ctions. Complete drawing on reverse side. x 2/f .� <br /> Signed <br /> Title: — Date: r <br /> t, FpR PARTMENT.USE ONLY__ <br /> � �-` by ,-. .. Dais. Area <br /> Application Accepted w ; � - <br /> T ri Final Inspection b Date <br /> �i w Grout Inspection by ata <br /> ii Additional Comments: <br /> 1 Applicant - Return all copies to: San Joaquin Countq Public Health Services <br /> 1111 Environmental Health Permit/Services <br /> 445 N San Joaquin, pA Box 2009, Stkn, CA 95201 <br /> � <br /> FEE AMOUNT DU E AMO4,TTEDCK REM <br /> I H RECEIVED BY DA E PERMIT'N0. <br /> INFOEH13-2411trv.l/Ks f -i �_W_ <br /> EH 14.16 <br />