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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC <br /> ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 445 N SAN JOAQIITN, PHONE (209)468--3420 95201 ��� <br /> P O BOX 2009, STOCKTON, CA 1992 <br /> 'PERMIT E%PIRES ] YEAR FROM DATE ISSII t�L "I <br /> (Complete in Triplicate) « / /1�i �,s <br /> A/-SC s N <br /> Application is hereby"made to San"Joaquin county for a permit to construct and/or install the work herein-described. This <br /> uin County Ordinance NO. 549 and 1862 and the Rules and Regulations of San <br /> application is made in comPliance with San Joaq <br /> Joaquin county blit Health Services. <br /> O City <br /> Lot Size/Acreage <br /> Job Address t <br /> ' U(�IAddress Phone <br /> Owner's NameAq / <br /> r Address License No (, Phone <br /> Contractor DESTRUCTION Ci Out of Service well <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL AEpLACEMEN7 ... Monitoring Well Ll <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> SEWER LINES _ --/DISPOSAL FLD. PROP. LINE z, <br /> C DISTANCE TO NEAREST: SEPTIC TANK �`PIT515t71VlPS <br /> `=-AGRICULTURE WELL-_"_"OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (}� <br /> _ Dia. of Well Casing <br /> F1 Industrial $ ❑ Open Bottom is Manteca Dia. of Well Excavation - <br /> Type of Casing_ Specifications. <br /> C.I Domestic/Private ❑ Gravel Pack Ll Tracy Type of Grout <br /> Public f-1 Other , n Delta Depth of Grout Seal <br /> i I Irrigation Approx. Depth i I Eastern Surface 5eu1 installed by <br /> Repair Work Done Type_of_Pur: -- <br /> 1/0 State Work Done <br /> U � H.P. <br /> fl Sealing Material & Depth <br /> Well Destruction 0 Well Diameter R w <br /> ' tDepth �� ' _ Filler Materiel & Depth --_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIfllAODITION l I DESTRUCTION I 'aNaildbletw thin 200 lee.tit�ed if public sewer is <br /> il <br /> Installation will'serve: Residence Commercial Other <br /> Number of living units: NLmber of bedrooms ' e <br /> _ Water table depth r, <br /> Character of soil to a depth of 3 feet: " Na. Compartments <br /> SEPTIC TANK' y _O.Type/Mfg Capacity <br /> PKG. TREATMENT-PLT, ❑- - -" -�'t' Method of Disposal <br /> i = Foundation ' Property tine <br /> ^- Distance to nearest: Well <br /> LEACHING LINE W ❑ No. & Le <br /> ngth of lines Total length/size <br /> FILTER BED Cl Distance to nearest: We Foundation Property Line <br /> SEEPAGE PITS ; I i Depth f Size f Number <br /> SUMPS Ll Distance to nearest: Well foundation PropertyLim_ <br /> D SPOSAL POND S - <br /> I hereby certify that I have prepared this application and that tF a work will be done in accordance with San Joaquin county ordinances, state laws, and' <br /> i rules and regulations of the San Joaquin County f <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, 1 shall not <br /> employ any person in such manner as to become subjectfto workman's compensation laws of California-" Contractor's hiring or sub contracting signature <br /> certifies the follow' g "I Certify that in.the pertormance'ol the work"for which this permit is issued, I shall or pentons subject bject to workman's compensa <br /> tion laws of t <br /> The appIic t m tall for all required i pec ions omplete drawing on reverse side. ,. <br /> t _ i <br /> Signed x <br /> Title: Date: <br /> R DEPARTME T USE ONLY <br /> I Date �:_ Are—a , <br /> Application Accepted by - <br /> 1 LZ <br /> Pit or Grout inspection by "f Date Final Inspection by'G L' Data <br /> Additional Comments; 1 <br /> t <br /> Applicant I Return all copies to: San Joaquin County Public Health Services <br /> r <br /> Environmental Health Permit/Services -•,pw <br /> t 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 <br /> FEE CK IRECE= PERMIT"NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> j INFO f�} <br /> . £H 1324 IREV.i 145 l '� Y� f � <br /> EH 14.2a <br />