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APPLICATION aFOR 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 /> PMIT EXPIRES 1 Y FROM DATE 13S <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 costpllance with San Joaquin County ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. T <br /> Job Address <br /> 2331, 6, J A 1LALiV Q City Loa Got Size/Acreage <br /> I <br /> Address *"C-f Phone <br /> Owner's Name <br /> 1!t ) .�" j� { <br /> on MOP1�-+r i`�r `,� YV�A�C.+ Addr s� lJ Q i ense No.��Phone����� <br /> ervice well 0 <br /> TYPE Of WELL/PUMP: NEW WELL WELL REPLACEM NT ❑ DESTRUCTION ❑ Out Mon Monitoring Well ❑ <br /> PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK /� SEWER LINES IDISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL% OTHER WELL PITS/SUMPS <br /> —INTENDED-tiSE-�--- ;° TYPE-OF-WELL- -PROBLEM-AREA�CONSTRUCTION SPECIFICATIONS-----�-•--•� _ <br /> C1, ''d'ustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation" Dia. of Well Casing <br /> �ajnastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ i Type Specifications <br /> 1"1 Public 1-i Other n Delta Depth of Grout Seal Type of Grout <br /> Ircigation —.Approx. Depth I Eastern �I urface Sedi Installed by t <br /> Repair Work Done U Type of Pump H.P. <br /> ' State Work Done <br /> ' Well Destruction ❑ Well Diameter Sealing Material & Depth <br />"w 5. _Depth Piller Notarial i Depth 6' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i -REPAIR/ADDITION I I DESTRUCTION I I ;No septic system permitted if public sower is <br /> e ! <br /> available-within 200 feet.) <br /> Installation will serve: Residence CommerciaFt- Other <br /> 4 Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK ❑ 1Type/Mfg Capacity No. Compartments I <br /> PKG1 TREATMENT PLTX' E i. Method of Disposal _ZZ <br /> Distance to ne$rest� Well Foundation Property Line <br /> �LL <br /> LEACHING LINE 10 No. A Length of lines Total length/sire <br /> FILTER BED.o .. r Cl Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l 1 Depth Site Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Lina <br />!! DISPOSAL PONDS ❑, AM <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, t�tait ,4, and <br /> rules and regulations of the Son'Voafquin County %I <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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicantt call fo ed i trona. Complete drawing on revs side. Al2- <br /> Signed Title: Data: r <br /> FOR DEPARTMENT USE ONLY <br /> ( all CIL <br /> Application Accepted by ` Date Area <br /> f Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health Services <br /> Environmental Health Permit/Services <br /> 445 H San Joaquin, P O Box 2009, .Stkn, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. <br /> INFO q ,y <br /> . EM 13.24(REV,I/K!5) � sf� 1 <br /> EM 14.26 /yy� <br />