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APPLICATION FOR PERMIT <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 /> PERM T EXPIRES 1 YEAR FROM D TE ISSUED <br /> (Complete in Triplicate) <br /> Aypl'ricttion is hereby made to Elan Joaquin County for a permit to construct and/or install the work herein described. This <br /> syplicatioo=ls wade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Elan <br /> Josquin Count- Public Health Servi s. <br /> Job Address �ecity 4Aree,4 Lot SizelAcreage / <br /> Owner's Name P'"�'�" Address � � iI-_� Phonh <br /> ontractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT DESTRUCTION ❑ Out of Service Yell_17❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ Monitor`ing Yell <br /> .DISTANCE TO NEAREST: SEPTIC TANK SEWER LI DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE ELL Z OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA r CONS CTION SPECIFICATIONJS <br /> -Cl Industrial O Open Bottom ❑ Manteca 'AJ pia We xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty of CasingNby <br /> Specifications <br /> —Il Public n Other I-1 Delta epth of Grout Type of Grout r <br /> I I Irrigation <br /> g Approx. Depth I I Eastern ,-Surf ace Seal ln � - ; \"�v\• <br /> «` Repair Work Done Type of Pump H.PorkoWell Destruction ❑ Well'Diameter .ling Irfaterial i DcpVii, C 1 <br /> Depth biller l4terial,�i Depth—: _ <br /> e_4 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I IN. septic system pgrmitted,il!public sewer is <br /> available within 200,feet.l <br /> Installation will serve: Residence X Commercial T Other i <br /> Number of living units: Number of bodroomi- _ <br /> Character of soil to a depth of 3 feet: . . <br /> Water table depth <br /> I SEPTIC TANK O Type/Mfg `r' Capacity Q-00 _ No. Compartments �` T <br /> PKG. TREATMENT PLT.0A "" ' -. rt Method.of D',�spdsai <br /> . i <br /> Distance to nearest: Welt /moi ra�_-46,ridatiori 7 y- :.Property Line • 3.B <br /> LEACHING LINE ❑ No. 8 Length of lines f1 Totes length/size r <br /> FILTER BED 0 Distance to nearest: Well. r <br /> ,/�,.,�. Foundation property Line ! -3�:•_ <br /> t SEEP GE PITS <br /> 11 Dept Size Number <br /> SUMS istsncs newest: Foundati Props <br /> DIS <br /> S PONDS ❑ <br /> "I herec <br /> by artily 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 Joaquin County <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." Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this porn-tit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of <br /> hes a t mu tali for all requir speptions. Complete drawing on reverse side. <br /> Signed �t-+�Q�[rv� Title: Date: d <br /> r <br /> F R IPARTMENT USE ONLY <br /> Application Accepted byaQ <br /> ✓ Date A ea <br /> Pit or Grout inspection by Date Final Inspection b t <br /> ate <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 Box 2009, Stkn,-CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED >t RECEIVED BY DAT PERM17'N0. <br /> . EN SE•2�IItEV.i i n sr �N 1� t o-� /� � /� <br /> EN taza / <br /> y '� <br />