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E <br /> APPLICATION FOR PERMIT <br /> T # <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ` ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUW <br /> (Complete in Triplicate) i <br /> - i <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or instal1 the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 "'the Rules and Regulations of San <br /> Joaquin County Public Health Services.. - <br /> Job Address ._ V 5 _ City Lot Size/Acreage" <br /> Owner's Name / Address <br /> Contracto f Addres S• License N Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service well ❑ <br /> PUMP INSTALLATION C1SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C} Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing s <br /> C7 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing. Specifications <br /> I"1 Public l-1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern;-*—"'- "Surfico Spal Installed by ' <br /> t V <br /> Repair Work Done 0 Type of Pump H.P. State Work pone <br /> Well Destruction t� Well Diameter !Ct", F +ding llaterisl i Depth <br /> Depth.'r�rv-- ;Filler Material i Depth <br /> WF <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> m ' available within 200 feet.) <br /> a <br /> Installation will serve: Residence_ Commercial_�--Other <br /> Number of living units: Number of bedrooms <br /> Character of sou to a depth of 3 feet: 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r- Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 -- j Method of Disposal ' <br /> t l <br /> Distance to nearest: Q WeII Foundation - Property Line <br /> ` 4 <br /> LEACHING LINE 0 No. m Length of lines Total length/size <br /> FILTER BED G1 Distance to nearest: Well Foundation Property Line �- <br /> SEEPAGE ITS I I Depth Size Number <br /> SUMPS Ll Distance to neer"t: Well Foundation Property Line <br /> I� DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, itats laws, and <br /> rules and regulations of the San Joaquin County ; <br /> Home owner or licensed agent's signature ceirtifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contricting signature <br /> certifies the following: "I certify that in the performance of the_work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> N <br /> E The applic 11 rail r ed inspections. Complete drawing on r arse <br /> sid <br /> Signed Titl Date: <br /> F R DEPARTMENT Y j <br /> i t <br /> s. Application Accepted by r Date Z res <br /> c <br /> F Pit or Grout Inspection by Date Final Inspact1onL4bbZ Detb� <br /> Additional Comments: <br /> J <br /> Applicant - Return all copies to: San Joaquin County"Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2000, Stkn, CA 95201 <br /> aE <br /> AMOUNT DUE AMOUNT REMITTED CASH RECEIVER BY GATE PERMIT'NO: <br /> j <br /> . EM 13.2 I#tv,1/Rai4�o, o (o c�• 1�t3 6 <br /> i <br /> EX 14.21 <br /> i �+f <br />