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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTALCO1 <br /> SION <br /> P o sox 2009, SOCKTN, CA 95201 <br /> (2Q9) 468— -73')-r'-0 <br /> Y R R <br /> (Complete is Triplicate) <br /> vork <br /> in <br /> Application is hereby made,tlolaSCn Joaquin <br /> county fora pe mitOrdtonconstruct and and/or <br /> install <br /> and theeRules and Regulations dof San <br /> s <br /> application is made �A <br /> Joaquin County Public Health)+se}rvice , Lot Size/Acreage <br /> 6 LU/ _JC ILE City s <br /> Ile <br /> Job Address �-�. <br /> r---�s �. . t <br /> Address hone <br /> Owner's Na e / � � �r•�L'}/ <br /> j Tw�jI�►" License N '7�a /C'_____�----•— 'hon <br /> Contract � i Address t of Service Hell ❑ <br /> r WELL REPLACEMENT ❑ DESTRUCTION <br /> ` TYPE Of WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well �� _ « <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] <br /> PROP. LINE <br /> SEWER LINES � DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK �-- OTHER WELL_.____.. PITS/SUMPS <br /> FOUNDATION �� AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ open Bottom ❑ Man t — Dia. of Well Excavation <br /> f_7industrial `� Specifications <br /> ❑ Tracy - T.Ype of,Casing <br /> U Domestic/Private ❑ Gravel Pack "� ""'� :.Type of u <br /> I. M Public <br /> 1-1 Other �© Delta Depth of Grout Seal , <br /> C.I Irrigation �.Approx. Depth . ❑ Eastern �,t Surface 5ea1 Installed by <br /> { <br /> Repair Work Dons U Type of Pump i M P State Work Done <br /> �_-=--� Sealing Material i Depth V ' <br /> Well Destruction C) Well Diameter f filler Material 4 Depth <br /> Depth ' septEmitted it public sewer is <br /> TYPE OF SEPTIC WOflK: NEW INSTALLATION L1 _.REPA RIADDITION CI DESTRUCTION CI BNailabletw thin 200 feet.1 <br /> installation will serve: Residence �Cammercial Other._ ; <br /> NumtSer of living units: Number of-bedrooms t <br /> r <br /> Water table depth <br /> Character of soil to a depth of 3 feel: ` No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Capacity,��.— <br /> 4 Method of Disposal <br /> ' PKG. TREATMENT PLT. C3 - <br /> Distance to nearest: Well Foundation _..� Property Line ; <br /> Total length/size <br /> LEACHING LINE Cl No. & Length of lines property Line <br /> FILTERDistance to,-nearest: Well Foundation <br /> � fILTER BEDr <br /> Size Number <br /> SEEPAGE PITS ii Depth property Line_------ - <br /> SUMPS LI Distanca tc nearest: i,-Weil Foundation <br /> 'DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that the work wM be done in accordance with San Joaquin county ordinances, stale laws, and <br /> rules and(agulaflons of the Son Joaquin County <br /> Home owner or lic sed agent's signature certifies the following: "1 certify that in the performance at the work for which this permit is issued, l shall not <br /> employ any person i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the followi -I certify that in I pert an of the work for which this permit is issued, I shall employ persons subject to workman's Compenca• i <br /> r tion laws of Cel' n <br /> The ap icon! st a ,for all re inspection , C late drawin d9. <br /> S ad <br /> . _ <br /> Date: <br /> Title <br /> r 9 �ti <br /> EPARTMENT USE ONLY <br /> { Date rea <br /> Application Accepted y <br /> Pit or Grout Inspection by Date — Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, p O BOX 2048, STOCKTON. CA 85201 <br /> FCK RECEIVED BY DATE PERMIT"NO. <br /> EE <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO 0 3 <br /> . EN t3.241Rev.r)nsi <br /> EK 36 2e <br />