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APPLICATION FOR PERMIT 0 G f G <br /> IC HEALTH SERVICES � - . <br /> SAN JOAQUIN COUNTY L ERALTH DIVISION y 1 f <br /> ENVIRONMENTAL <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERK T <br /> (Complete in Triplicate) <br /> Application is hereby taade to San Joaquin County for a permit to construct and/or install the cork herein described. This <br /> a lication is mere in castpliance with Ben Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Public Health Services. <br /> Joaquin County t Size/Acreage ' <br /> cr city ��Lo <br /> lob Address I 3� -71 <br /> �/ d S r1'�Q flgAddress n Phone <br /> l�Ow �� <br /> ner's Name � <br /> License No. �'_Phone <br /> ntractor Address put of Service well L1 <br /> WELL REPLACEMENT ❑ DESTRUCTION Ll <br /> TYPE OF WELL/PUMP! NEW WELL ❑ OTHER ❑ Monitoring well <br /> SYSTEM REPAIR 0 <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES ��--� DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK ,.�� OTHER WELL— PITS/SUMPS <br /> FOUNDATION — AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> p Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> E7 Industrial Type of Casing_. <br /> C] OomesticlPrivate Cl Gravel Pack ❑ Tracy of Grout <br /> i.1Other i'1 Datta Dept h of rot - �) <br /> I'l Public I al d b <br /> I l Irrigation —Approx. Depth I ! Eastern k e <br /> of Pump �—�- H.P. P..,� <br /> Repair Work Done U Types Seeli,rg t:eri & Dep h <br /> n p Well Diameter _ <br /> to <br /> I attract �Jth' <br /> Wel D filler ��i� F <br /> Depth rmitte4sewers <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlAD I fest)01011 <br /> Installation will serve: Residence--- Commercial— Other <br /> Number of bedroomsNumber a} Inring units: Water table depth <br /> Character of&ON to a depth of 3 feet: Capacity�.�--- No. CompartmentsSEPTIC TANK. O Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property LineDistance to nearest: WeFoundation <br /> Total length/size <br /> LEACHING LINE EI No. b Length of lines Property Lina <br /> FILTER SED Cl Distance to nearest: Well Foundatiori �— <br /> Size Number <br /> 1I Depth <br /> I SEEPAGE PITS <br /> SUMPS L1 Distance to nearest: Well Foundation property Line <br /> DISPOSAL PONDS ❑ <br /> is application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> I hereby certify that l have prepared th <br /> rubs and regulations of the San Joaquin County <br /> olVowing: "I certify that in the performance of the work for which this permit is issued, I shah net <br /> Homs owner or licensed agent's signature certifies the I <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 11te foNowing: -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 applicant must call far all required inspections. Complete drawing on reverse side. �� � <br /> I Title: [7� e. � Date: <br /> SignedX. <br /> l OR DEPARTMENT USE ONLY C� <br /> � Date��'��! L _ Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date — <br /> Final Inspection by Data�.-- <br /> Additional Comments: <br /> Applicant - Return all copies to: EnCounty Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED By DATE PERMIT'aNOFEEEMETEE <br /> CASH <br /> INFO �J <br /> . EH 1124{t1EY.v 11%61 Err 11.20 <br />