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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> PENVIRONMENTAL HEALTH DIVISION <br /> O BOX 2009, STOCKTON, CA 95201 <br /> I (209) 468-3447 <br /> PgamTT EXPIRES 1 Y$AR DATEISSUZM <br /> (Complete in Triplicate) <br /> �3` <br /> ApplicatLon 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 coai+lisnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services j� <br /> Job Address <br /> 3� / ' rT4V,&,0` Cit Lot Size/Acreage <br /> "1 <br /> < Phone <br /> Owner's Na - Address - - <br /> • Contract � Addre <br /> O fp 0(71' License Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out or Service Well Monitoring Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR F✓ OTHER ❑ <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 /> 0 Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> EJ Domestic/Private ❑ Gravel Pack . ❑ Tracy Type of Casing Specifications <br /> ❑ Public fa Other . ❑ Delta Depth of Grout Sea! Type of Grout ` <br /> 0 Irrigation Ap-prorr.::Depth �D Eastern. Suriece Seal InsiSlled by Np,, <br /> Repair Work Done lY Type of Pumper �H P ' t State Work Done Wn^ <br /> Wall Destruction O Well Diameter Sealing PAterial i Depth I <br /> Depth Filler Material i Depth -13 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION C1—DESTRUCTION LtTlido'stiptie-System'perir;irted it public sewer is 'n <br /> available within 200 feat.I J 1 <br /> Installation will serve: Residence Commercial Other ' <br /> Number of living units: Number-of bedrooms f e <br /> Character of soil to a depth of 3 feet: Water tabu depth <br /> SEPTIC TANK ❑ Type/Mfg:! Capacity. No. Compartments <br /> PKG, TREATMENT PLT, 0 J �AAMUGi posal <br /> Distance to nearest Well Foundation Pref"VEID, <br /> LEACHING LINE C1 No. 8 Length of lines Total longlJt9 1992 <br /> siz <br /> FILTER BED ❑ Distance to � 3Liu H�RL <br /> nearest: Well Foundation SAL HEAL-+la��I IItiTY <br /> � � 7-H 5EF2VME-5 <br /> SEEPAGE PITS 11 Depth Size Num er <br /> I I a DIVISION <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 <br /> rules and regulations of the San Joaquiri'County <br /> Home owner or licensed agent's signature canities the fallowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to tiecome subject to workman's compensation laws of Calilornia." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit its tissued, i shall employ persons subject to workman's compensate= <br /> tion laws of Californ <br /> The applicant m 11 o 11 required ies tions. Complete drawing on rse side: <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 7,A q2 Area ICJ <br /> Pit or Grout inspection by Date Final Inspection by oats gZ <br /> Additional Comments: 1 <br /> Applicant - Return all copies toi SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE :I AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'Np. <br /> INFO <br /> . EK 11•24 IREV.1 95r 3003 6-r) / L 1 —2 • J . <br /> j EH.4.m <br /> I �e <br />