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<br /> APPLICATION FOR PERMIT
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<br /> AN J6A4U, N 6duN,, 'X PUBLIC HEALTH SERVICES ;t _
<br /> ENVIRONMENTAL HEALTH DIVISION
<br /> P 0 BOX 2009, `STOCSTON', CAS 95201
<br /> (209)' 468-3447
<br /> RMIT ESPIRES 1 MAR 980M PATE .ISSUED �
<br /> (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
<br /> Address - Nit'/ � � �! ,lLot
<br /> 4.L > U.,., ,.,...T.-- — City _ /Acreage
<br /> Ap
<br /> Owner's Name �1�Q�Z Address
<br /> --'— ..,a-.-..,,...r=fig:::--.,..:------�..
<br /> Contractor Address_ _� 1r1�� � f1. License NOv �Phone
<br /> TYPE OF,WELL/PUMP: _ NEW,WELL 0 WELL REPLACEMENT.n 'DESTRUCTION 0 Out of Service Well Cl,
<br /> r,
<br /> PUMP INSTALLATION 0 "` SYSTEM-REPAIR,❑ i Fi OTHER'❑ Monitoring Well C7 f
<br /> } r '
<br /> DISTANCE TO NEAREST: SEPTIC TANK .'^' `SEWER LINES DISPOSAL'FLD: PA P. LINE
<br /> `? FOUNDATION: - AGRICULTURE WELL s OTHER-WELL PITS/SUMPS
<br /> INTENDED USE TYPE OF_WEL'i PROBLEM AREA CONSTRUCTION SPECIFICATIONS k
<br /> n Industrial z ❑ Open Bottom-. t0 Manteca Dia;of Well.Excavalion Dia, of Well Casing
<br /> U Domestic/Private• Ll.Gravel Pack. O Tracy Type of Casing Specifications
<br /> Other 0 Delta Depth of Grout Seal Type of Grout _
<br /> CJ Initiations Approx. 'Depth ❑Eastern Surface Seallnstalled by
<br /> Repair Work Done .U,, Typa.of Pump"._ _ � _H.P.. d �_State Work Done
<br /> Well Destruction Q Wait Diameters Sealing ttfaterisCliDeptti"s' " _ 'i'
<br /> f 1
<br /> Filler Material i Depth:
<br /> ` - Depth ' F • �
<br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITtON`I� DESTRUCTION CJ (No.septic system permuted if public sewer is
<br /> r i
<br /> -A ,/ ('' r available within,200 leit.i
<br /> Installation will serve: Residence,._ .Comrriarcltil Other " """ �. " ,1,
<br />_ Number of living units: 4 Number bedrooms
<br /> ,.gharactor of twit to a depth of.3•feet: �� 'Water table depth Y
<br /> SEPTIC TANK; ❑- -Type/Mfg — Capacity, No.-Compartments
<br /> PKG, TREATMENT PLT.L7 x % Method of Disposal N
<br /> Distance to nearest: Well Foundation �D �' Property Line
<br /> LEACHING LINE No.,16 Length of linesTotal length/size.
<br /> A
<br /> FILTER BED [ Distance to-nearest: Wel! Foundation lO T Property Line
<br /> SEEPAGE PITS, Y I biiipth, T $ire Y Number
<br /> SUMPSDistanca to,nearest: WeH Foundation Pro
<br /> party Line
<br /> DISPOSAL PONDS ❑
<br /> I hereby comity that f have prepared this application and that the work will be-done In sccordance�with SariJoaquin county ordinances, state laws, and
<br /> rules and regulations of the•San Joaquin ;'County i - -
<br /> Home owner or licensed agent's signeture'cenifies the following: "I certify that in the perforrtiance ofthework 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 sub-contracting signature
<br /> certifies the following: "I certify that,in the,pertormance of the work for which this permit is issusd;'1 shall employ persons subject to workman's compensa-
<br /> tion laws of California."
<br /> The applicant must call for.#1 required inspections. Complete drawing on reverse side''. _
<br /> Signed Title _ Data:
<br /> F • . PARTMENT.USE ONtY`.r'-
<br /> Application Accepted by Date r Area `
<br /> U
<br /> Pit or Grout Inspection by Date Finaltlnspection byL Date
<br /> Additional Comments, {
<br /> Applicant - Return all copies to: "gANJOAQUIN COUNTY PUBLIC HEALTH.—SERVICESr
<br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES.;
<br /> CX "~ 1
<br /> " 449 N SAN ,JOAQUIN, F 0 BOX 2009, STOTON, 'CA 98201
<br /> -IEEE ..AMOUNT DUE. - _ .. CK _
<br /> INFO 9 AMOUNT REMITTED .CASH h- RECEIVED Bye DATE 'PERMI7'NO.
<br /> EH 76;1
<br /> EK 13.24(REV.ii�5i S/,,i LLQ ® (
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