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i <br /> I� APPLICATION FOR PBRMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCHTON, CA 95201 <br /> (209) 468-3.447 ; <br /> VQ I VRAR <br /> ii (Complete in Triplicate) <br /> Application is hereby made tto San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in cetWllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> City��w - Lot Site/Acreage -- <br /> Job Address / [� <br /> /_ T ,D•$�Ct� Address "� Cct Phone <br /> Owner's Name�-- --T'-- ^^ ' <br /> iI Contractor <br /> Address -V • License No q! Phone3�, Z <br /> TYPE �. NEW WELL REPLACEMENT f� DESTRUCTION ❑ Out of Service Nell 0OF WELL/PUMP: WELL <br /> PUMP INSTALLATIONX SYSTEM REPAIR ❑ <br /> OTHER C] Monitoring Well C1 <br /> i _. SEWER LINES DISPOSAL FLD. t PROP. LINE <br /> LIED <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS , J <br /> FOUNDATION AGRICULTURE WELL'`= OTHER WELL - <br /> INTENDEO USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ATIO S Dia:.of Wall Casing r <br /> f_7 Industrial Open Bottom ❑ Manteca Dia. of Well Excavatio t <br /> Type of Casing <br /> Specifications <br /> ,�9omestio/Private Cl Gravel Pack O Tracy Y ' Type f Grout <br /> ublic 1-11 Other 0 Delta Depth of Grout Seal Type ' �G <br /> I awl trfigation cj��LG..'Approx, Depth Eastern rS rlace Sea! <br /> Installed by <br /> l r H p ,3 State Work Done_ <br /> Repair Work Dona U Type 4f Pump L2 Sealing MateTlali&•Depth <br /> Well Destruction O Well Diameter Filler-Material"', <br /> iller-Material&Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRIADDITION LI DESTRUCTION �3 afvailabe within 200 leet�sled 4 public sewer is <br /> iI <br /> Installation will serve: Residence_.. Commercial _.._ Other_ _/ <br /> Number of living units: Number of bedrooms ! '/ �, 1 <br /> Character of soil to a depth of 3 feet: W I '.table,depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity Na: Compartments ` <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation /Prope ty Line <br /> Imo'' <br /> LEACHING LINE ❑ No. 8 Length of lines •�Tota length/sizer€ � <br /> FILTER BED 1=1 Distance to nearest: Walt Foundation � PPapertyL Ina <br /> 1,Number <br /> SEEPAGE PITS 11 Depth Sixe .# <br /> SUMPS LI Distance to nearest: Weil Foundation Property <br /> Line tO- <br /> DISPOSAL PONDS D ,1 ' <br /> i application and that the work will be done in sccorcl nce with San Joaquin county ordinances, state Taws, and'' t <br /> 1 hereby certify that I have prepared this app <' <br /> �.;� rules end�egiiletionn Gf trie"San':toa�'7i in`Cb3fit�"""-'-"-""'""'�"�•�'• '� <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 /> 1-4 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certilies 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 /> -cion laws of California." <br /> i a The applicant ust call for all r quir inspections. Complete drawing on reverse side. <br /> Date. <br /> Sign <br /> Sian d Title: <br /> t F Ali FOR DEPARTMENT USE ONLY <br /> i <br /> Applic to coapted by �-'+ Q Date Area t C <br /> f Final Inspection b Data /pit or rout'inspection by � Date S-22-471 Y <br /> t <br /> A6diti a omments: _ <br /> Appli - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> + ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTE0Y4 ''G'A5H _ RECEIVED BY� DATE PERM11 NO. <br /> IN 0____ <br /> _ _ - <br /> ►" j I� Ji <br /> t . <br /> EH 17•74 irlEV.1 INS) <br /> EH.426 <br />