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ti r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009 , STOCKTON , CA 95201 � <br /> P (209) 468-3447 € <br /> Y g R <br /> ' l <br /> (Complete in Triplicate) <br /> • Sa J�osquin Cattnty faro Pe ordto inancenNO-u549ct aando1862aand thetall Rules and eRegulationslbedor Sana <br /> Application le he in descr <br /> llance with San Joaquin County <br /> application i <br /> Joaquin County Public Health Services. t Size/Acreage <br /> � r 03 city a , <br /> Z•�! <br /> Job Address � <br /> S &Q �. Fftt .�'n Phone <br /> (ZooTr� t-OIY'� Address f�f1/ f� 53�+� <br /> Phone <br /> Owner's Name q(.o <br /> Address va Z$ G M '"`�`� License No.�---- <br /> Contractory DESTRUCTION Cl Out or Service Well Cl <br /> NEW WELL © WELL REPLACEMENT C! OTHER��{{ Mottitorl well C7 <br /> TYPE OF WELL/PUMP: r SYSTEM REPAIR ❑ X G�® L F-IfP-tf11 t <br /> PUMP INSTALLATION ❑ DISPQSAL FLD.� PROP. LINE $ n <br /> DISTANCE TO NEAREST: SEPTIC TANK r-- SEWER LINES ^��- PITS/SUMPS4I <br /> f t AGRICULTURE WELL tt - OTHER WELL �— <br /> f FOUNDATION <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Open Bottom ❑ Manteca. Dia. of Well Excavation <br /> C7 Industrial Specifications <br /> Type of Casing <br /> - U Domestic/Private ❑ Gravel Pac� n Tracy Type of Grout <br /> I') Other ❑ Delta Depth of Grout Seal <br /> JWV <br /> M Public Surface Seal Installed by <br /> C.i lrrigation _ Approx.+Depth ❑ Eastern H.P.of Pump State Work Done <br /> ..�� <br /> Repair Work Done ❑ TYPa - Sealing Material i Depth <br /> Well Destruction ❑ Well Diameter - <br /> Filler Material i Depth <br /> Depthmitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPA4RlADDITION G DESTRUCTION ClG availablelwthin 200 feet." <br /> t <br /> I N <br /> } Installation will serve: Residence Commercial_ Other�-�- <br /> Number of living units: Number of bedrooms Water table depth <br /> , <br /> Character of soil to a depth of 3 feet: Capacity_ -- No. Compartments <br /> r - <br /> SEPTIC TANK © Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Foundation Property Line_��--- <br /> Distance to nearest: Well \ <br /> �t <br /> Total length/size 1 <br /> I LEACHING LINE ❑ No. & Length of Sines <br /> Foundation — Property Line <br /> FILTER BED n Distance to nearest: Well r_ <br /> I Number <br /> PAGE PITS I I Depth Sire <br /> SEE <br /> f Foundation Property Line—�-� <br /> k SUMPS LI Distance to nearest: Well — <br /> f DISPOSAL PONDS ❑ <br /> l will be done in accordance with San Joaquin County ordinances, state laws, and <br /> hereby certify that I have prepared this application and that the work <br /> rules and regulations of the San Joaquin County g: ork for <br /> Home owner or licensed agent's ergas tobecome subject workman crtCompensation lawsoai California.**Contractor's lhiri g of s sthis ub-contracting contract is e ngtsignatuore <br /> If employ any person in such ma l arsons subject to workman's compensa- <br /> i certifies the following: "1 certify that in the performance of the work for which this permit is issued. I shall employ P <br /> lion laws of California." f <br /> The appfic t m st call for all require inspections. Complete drawing on reverse side. Date. ! 9 Z <br /> Title: . <br /> Signed 4 <br /> Sc) _�f. pG�S F D ARTMENT USE ONLY 1 Q' <br /> r Area D <br /> Date <br /> Application Accepted by - Data", <br /> pate _, _ Final Inspection <br /> b - <br /> Pit or Grout Inspection y t <br /> Additional Comments: <br /> TH SERV <br /> Applicant - Return U ICES <br /> all copies to: ENVIRONMENTALOHEALTH DIVISION UNTY PUBLIC LPERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> CX sAEGEIVED 6Y ATE PERMIT NO,/., <br /> I FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO <br /> EM 53-74 trrEV. i i n�i S M •� "'-�,a.d <br /> EH :4.216 ii�� <br />