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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY 'PUBLIC <br /> HEALTHALTH SERVICES <br /> ENVIRONMENTAL HEALTH <br /> ON <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMd T 9" <br /> IRES Y FR If D TE <br /> . (Complete in Triplicate) <br /> S <br /> t to construct and/or install the work herein described. This <br /> Application is hereby <br /> made to San Joaquin County for a perms tions of San <br /> application is made in eee�liance with Ban Joequin County Ordinance No. 51+9 end 1862 and the Rules and Regulations <br /> Joaquin County Public Healtb Services'. t Size/Acreage <br /> ��✓ w I <br /> • -® <br /> Job Address /� �(' <br /> 11 - -7`v mess �U ` Phone <br /> Ow is Na �� <br /> ens No. hone <br /> n DESTRUCTION ❑ Out of Service Well L1 <br /> NEW WELL ❑ WELL REPLACEMENT n OTHER ❑ Monitoring Well CZ <br /> TYP£OF WELLlPUMP: SYSTEM REPAiR� <br /> PUMP INSTALLATION O DISPOSAL FLD. PROP. LINE <br /> SEWER LINES �-� - PITS/SUMPS .� <br /> DISTANCE 70 NEAREST: SEPTIC TANK -- AGRICULTURE WELL OTHER WELL <br /> FOUNDATION � - _� _ T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSf" Dia, of Well Casing <br /> Dia. of Well Excavation <br /> I-]��rlP,0.blsc <br /> utn&I © Open Bottom ❑ Manteca Specifications <br /> n Tracy Type of Casing - Grout <br /> most <br /> C1 Gravel Pack Depth of Grout`Seal Type <br /> n Delta <br /> til Other <br /> , rface S stalled by <br /> i I Irrigation -.Approx. De t 1 stern State Work Done — <br /> H'P' <br /> Repair Work Done U of Pump Type Sealing;lfsterial.i Depth <br /> "Well Diameter"��-- t <br /> Well Destruction ❑ Filler Materiel i Depth <br /> I Depth ' <br /> ,k I available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLA710N t I REPAIR/AV I l�DESTRUC710N I I INo septic system permitted it a �c sewer i <br /> At <br /> l Installation will serve: Residence <br /> Commercial — Other <br /> kNumber of bedrooms <br /> Number of living units: Water table depth <br /> Character of soil to a depth of$feet: Cspacity� No. Compartments <br /> SEPTIC TANK. ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.0 foundation Property Line��-- <br /> F Distance to nearest: Well <br /> fTotal length/size <br /> LEACHING LINE ❑ DisNo.tance <br /> b Length-of <br /> to neaS linearest: Well Foundation_ Property Line <br /> FILTER BED ❑ DisT <br /> Size Number <br /> SEEPAGE PITS 11 Depth Property Line <br /> CI Distance to nearest: Well Foundation__ ____�-- <br /> SUMPS � <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application end that the work will be done in accordance with San Joaquin count ordinances, state laws, and <br /> rules and regulations of the Sen Joaquin County g: <br /> rmit is issued, <br /> Home owner or licensed agent's signature certifies the onn workmans compensation.lawsool_Caiifornia.;-Contractor s-hiring oich this Psub-cont actng gnlature <br /> employ any person iin such manner as to become subjectPersons subject to work n's compensa- <br /> certifies the fopowing:,"I cortity at in thi,psrtormance of the work for which this permit is issued,l shall employ <br /> tion law's of 4K, + <br /> The a ica st cap for all ad ins ttions Complete drawing on r rse I �! <br /> Date: <br /> Tit � <br /> FOR DE ARTMENT USE ONLY { � <br /> e <br /> 1 Application Accepted by a <br /> Date � Area <br /> Date Final inspection by <br /> Date ' <br /> Pit or Grout Inspection by x <br /> T <br /> Additionsl Comments, <br /> I Applieant ­Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, .p O Box 2009, Stkn, CA 55201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT REMITTED <br /> NFO �� AMOUNT DUE GASH <br /> s. EH tS•24(REV.1/N 61 � - <br /> EH 14.20 - <br />