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APPLICATION FOR PERI[I T <br /> n SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r <br /> r� V ENVIRONMENTAL HEALTH DIVISION r� " <br /> l/ 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ERM T ESPIRES 1 YEAR FROM DATE ISSUEDNO <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and'1662 and the Rules and Regulations of Sari <br /> Joaquin County Public Health Services. <br /> C <br /> Job Address r 33 RAd Au City � Lot Size/Acreage <br /> Su I tiadeer- -/- � o,n d v"Prn0- G1 t��3 �,P-a,( 1'r!P f �- 7 S�/O ' <br /> Owner's Namee Address Phone <br /> Contractor_oj:gr .y�'�P — __Address License No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public Cl Other f l Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern t Surface Seal Installed by <br /> Repair Work Done Q., Typs,of Pump_ H.P.1 State Work Done_ <br /> Well Destruction D Well Diameter _ -Sealing ka1terial i Depth „ +. <br /> Depth li <br /> TYPE Of SEPTIC WORK: NEW INSTA' � ^IrrIOPU.l IV No septic system permitted i tic sewer is <br /> / available within 200 foe <br /> installatio rve: Residence �(19/9�� �� ( - <br /> Number of living units: Numf <br /> Character of sok to a depth of 3 f <br /> SEPTIC TANK. , ❑ Type/Mfr <br /> PKG. TREATMENT PLT.❑ yCjyl� J <br /> t Distance <br /> ,F <br /> LEACHING LINE, .[I No. b Lr /� iJl�� j`f"� <br /> FILTER B£_O O- Distanc# <br /> SEEPAGE PITS Depth <br /> SUMPS LIQ Distant <br /> DISPOS NDS ❑s- <br /> I eby certify that I have prepared ! fate laws, and <br /> rubs and regufations of the San Joa? <br /> Home owner or licensed agent's sign ued, I shall not <br /> employ any person in such manner a­ icting signature <br /> Certifies the following:"I certify that in[hs en's oompansa <br /> tion taws of California." <br /> The applicantatVi for all r ired inspection@. Complete drawing on reverse side. <br /> I/,Sigrad ^Title: Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date,�; .�_ Araa {,2 7-1 ._ <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant °- Return all copies to: San Joaquin County Public Health Services <br /> Y Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />! <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO. <br /> INFO C CASH <br /> . EH 13.24(AEV.1 0%5i ,,t'N <br /> EH u•n �J i� <br />