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3 <br /> r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> �( P O BOB 2008, STOCKTON, CA 85201 <br /> (209) 488-3447 <br /> PER11tIT EXPIRES 1 YEAR_ ZROM DATE _IBBUED <br /> (Complete in Triplicate) <br /> Application is hereby Stade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is teams in eowliance vibh_San Joaquin County Ordinance No. 549 and,102 and the Rules saw Regulations of San <br /> Joaquin County Public Health Services. <br /> t, Job Address , /)�/XG� Cory l_��i�! Lot Size/Acreage PT/X <br /> Owner's Name <br /> Address ,P. ov• a►QC 0',�L _ Phone <br /> Contracts �� Address •. [� C/t`.1CCdv License Na Phone <br /> TYPE F WELL/RUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION t of k"Il <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHE ❑ Well- <br /> Monitoring well <br /> DISTANCE TO NEAREST: SVTtC'TANK SEWER LINES DISPOSAL FLO. PROPi'LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL`_._— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ll Industrial ❑ Open Bottom O Manteca Dia. of Web Excavation Dia. of V"Casing <br /> U Domestic/Private O Gravel Pack ❑ Tracy Type of Casing <br /> M Public (:)Other O Delta Depth of Grout Seal Type of Grout <br /> U Irrigation —Approx. Depth D Eastern Surface Seai Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> WON Destruction O WON Diamtter T— Sealing Material a Depth <br /> Depth Piller Material i`Depth, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION O REPAIR/ADDITION M DESTRUCTION G I o sept;-system pormittoO itpubNc sewer is <br /> available within 200 feet.)' <br /> Installation will some: Residence_ Commercial_. Other <br /> Number of living units: Number of bedrooms P <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. O Typo/Mfg Capsctty No. Compartntsnts <br /> PKG. TREATMENT PLT,0 Method of DhpaN <br /> Distance to nearest: Well Foundation: Property Line ;. <br /> LEACHING LINE C1 No.& Length of lino Total length/sit <br /> FILTER BED CI Distance to nearest: Wel foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well: Foundation Prop"Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 haw prepared this application and that the work will be done in accordance with San Joaquin county,ordimanoea,state lows, and <br /> rules and regulations of the Son Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, t SWI not <br /> employ arty person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-eontrac*V signature <br /> certifies the following: "I rtr that in the performance of the work for which this permit is issued, t/hall employ persons subs to workman's compsnas- <br /> tion laws of California.' <br /> The spplkant st call all tequlred inspections. Complete drawing on reverse side: <br /> " Signed TitIO: y t.o Date: <br /> FO SE ONLY <br /> Application Accepted by QnrAA' tt N. ,lMAe, Dote.._3. TPA T!, Arai $ <br /> Pit or Grout Inspection by Data Final Inspection by ' Das <br /> Addltional Comments: ^' <br /> Applicant • Return all copies to; SAN JOAQUIN COUNTY PUBLIC HSA4TII SgRV,100 <br /> INVIRONMENTAL HEALTH DIVISION¢.ftMIT/S2R*ICES, <br /> 445 N SAN JOAQUIN, P 0 BOX 2000, STOCKTON, CA 06201 <br /> CK 0 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEO CASH flEirf#Yl sy DATE PERMIT'NO. <br /> .ENtlZ4 tltEv. i et �© �0-V ©•aD 2( J . 1 ID c6 <br /> 114,4-n <br />