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APPLICATION FOR PERMIT <br /> J911 ii SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ?-o-1319-13 <br /> ��qq 3 <br /> jJ ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 GEN nZ A- K Y PtC- Pt^r..,T <br /> JUN 0 2 1993 P O BOX 2009, STOCKTON, CA 95201 16t3't QeLLTyN- COLA , <br /> E{�1/�RONMEMALHEALIN <br /> PERMIT EXPIRES YEAR R lIt DATE SU <br /> PERMMSERVICES (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address s c— CityS Lot Size/Acreage +� <br /> Owner's Nam�eTr � Lb LLQ Address Phone f <br /> Contract sass <br /> 2-6 ZS� F STticense N0. �Z� Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER Voll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. prt 5 <br /> r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL fI <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS to Dl <br /> C] Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Wall CA*anei_ <br /> 0 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ —&JA <br /> I'1 Public EI Other Fl Delta Depth of Grout Seal T�fyta-�f-G^crvt= �Ls. <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> Well Destruction © Well Diameter Sealing Material i Depth <br /> Depth Piller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted if public suwar is <br /> available within 200 feet.) <br /> Installation will servo: Residence— Commercial— Other <br /> Number of living units. Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE 0 No. A Length of lines Total lengthlsize <br /> FILTER BED 0 Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Lint <br /> DISPOSAL PONDS ❑ C <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and �Q <br /> rules and regulations of the San Joaquin County q{ <br /> Home owner or licensed agent's signature certifies 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." Contractors hiring or sub-contracting 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 /> The applicant sugt t call 1 required inspections. Complete drawing on reverse side. <br /> Signed X._ <br /> ' ,Esv6 EBF®i�3�I� --- Date: <br /> - Title: <br /> FO D RTMENT USE ONLY <br /> Application Accepted by Date a <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Hoa 2009, Stkn, GA 95201. <br /> FEE AMOUNT DUE AMOUNT REMITTED jrCK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> . EM13-24(REV <br /> EH 14.2 V� o r � 0--3-iolzd <br /> 4r. .,yw• <br /> itJ r L <br /> a <br />