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APPLICATION FOR PERMIT �---- ----- _` ` <br /> SAN JOAQUIN COUNTY PUBLIC HEALT��CS____ v <br /> ENVIRONMENTAL HEALTH DIVI ION <br /> 445 N SAN JOAQUIN, PHONE (209) <br /> P 0 BOX 2009, STOCKTON, CA O <br /> n �J <br /> (Complete in Triplicate D` ----- �� <br /> Application is hereby made to Etas Joaquin County for s permit to construct and/or install the work herein described. This <br /> application to wade is compliance with Elan Joaquin County Or+dlrawce No. 549 and 1862 and toe Aides and RogulAtiona of San <br /> Joaquin County Putlic Health Services. <br /> Job Address , LLQ °Z w City Lot Size/Acresae <br /> Owner's Name[ Address �v,S2 _ -S--,R ZLK.:V ` ,- S C.Phone <br /> y 2��_ I'/jr_ P License No �O SlD Phone <br /> Contracltx 'li Address <br /> TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION D SYSTEM REPAIR W OTHER ❑ Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PROP. LINE <br /> FOUNDATION _ __ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial O Open Sonom ❑ Manteca Dia of Well Excavation_ Dia. of Woo Casing <br /> Cl Domesticiplivste 0 Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> 1'1 P%"Ic Cl Other fl Delta Depth of Grout Sea) Type of Grout <br /> pC7rtylatron Appro■, Depth I Eastern Surface Saul lnzto!wd by <br /> Repair Work Dora Type of Pump -1csii H,P. State Work Dona <br /> WsN Destruction Cl Woo Diameter Searing Material Il 'Depth � <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I AEPAiRIADDiTON I I DESTRUCTION t I lNo septic system permitted it public &@war is <br /> available within 200 feet.) <br /> Installation will serve Residence_ Commercial — Other <br /> Number of living units: Number of bedrooms <br /> CMrecter of soll to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Componmants <br /> PKG, TAFATMENT PLT.❑ Method of Disposal t <br /> Distance to nearest: Well , Foundation Property Line t <br /> 1 <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED Cl Distance to nasrogu Well Foundation _ Property Line <br /> SEEPAGE PITS 11 Depth Sire Number _ <br /> SUMPS LI Distsnca to neatest: Weil Foundation Pfopirty Line <br /> 1 <br /> DISPOSAL PONDS Cl <br /> I hereby certify Ihat I have prepared this application and that the work will ba done in accordance with San Joaquin county ordmances, state laws, and <br /> rules end reputations of the San Joaquin County <br /> Homs owner or licensed agent's sgrmture certifies the following; "I certify that in the performance of the work for which this permit is*sued, I shall not <br /> employ any person in such nunrw 2s to beco ne subject to workmen's compensation laws of California."Contractors hiring or subcontracting signature <br /> cartifies the foEowing: "I certify that in the periormwnce of the work for which this parmh is issued. I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The appiic at c for ed required inspections, Complete drawing on (TIC side. <br /> Sipnad , � Title: Date: _ <br /> FOR DEPARTMENT USE ONLY <br /> .' <br /> Application Accepted by �-- Date Area L_ <br /> licat <br /> Pit or Grout Inapectbn by to Final Inspection by Datc L! <br /> Additional Connryients: <br /> Applicant - Return all copies to: San Joaquin County Public Health 6ervicea <br /> C ,j1 445 N Saenta2 Health Permit2009,icee � n l _ of l o ,l J <br /> V 445 N San Joaquin, Q O Box 2009, Stkn, CA 5201 (`�`((�J\/ l..t` `tT� <br /> IFEF�E AMOUNT DtlE AMLIUNT REMITTED CASH � RECEIVED By M1T N0. <br /> FM 1}24 tfIEV,If R51 J�.., . , it /1 ! 41e- 1t!"17a L y I 11�7/1 �cn AL <br />