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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC..HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ` ,� t.� <br /> 445 N SAN JOAQUIN, .PHONE (209)46$-3420 19L r V$ <br /> P O BOX 2009, STOCKTON, CA 95201,x{s%,, 1 �� <br /> EN�IR &(l �;�r <br /> -4 PERMIT EXPIRES 1_ YEAR FROM DAU I 81_1 <br /> C ?SD E �� (C'omplete in Triplicate) �''� � n/�Q/ s <br /> Application in made to San Joaquin County for a permit to construct and/or install the work herein d�EsslEJbed. This <br /> application is made in car�tliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County P b11c Health Services. 0_?o Ola R <br /> City Lot Size/Acreage <br /> Job Address <br /> 1 Phone <br /> Owner's Name +U Address -� <br /> i, <br /> } [ <br /> 5 License No.��Phone 1!� <br /> Contractor Address O <br /> TYPE OF WELL/PUMP: F NEW WELL ❑� WELL REPLACEMENT ❑ DESTRUCTION ❑ Out o{ Service Well <br /> SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ <br /> <PUMP INSTALLATION ❑ X <br /> F SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK � f <br /> FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r. <br /> INTENDED USE} TYPE OF WELL ;PROBLEM­AREA CONSTRUCTION SPECIFICATIONS <br /> Dia- of Well Excavation Dia. of Well Casing <br /> 0 Industrial f ❑ Open Bosom ❑ Manteca { <br /> } Type of Casing_ Specifications <br /> ["1 DontasticlPrivata ❑ Gravel Pack E] Tracy . <br /> W1169ati0f) <br /> ublic 11 Other Fl.Detta Depth of Grout Seal Type of Grout <br /> Approx. Dept 1 1 Eastern Surf Seal Installed by <br /> Repair Work Done LJ Type of Pump �SL H.P. State Work Done <br /> Well Destruction !❑ Well Diameter Sealing Material# Depth <br /> t Depth Tiller Nater1al i Depth_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted it public sewer is <br /> I <br /> available within 200 fest.l <br /> Installation will seen: Residence— Commercial Other t <br /> Number of living units: Number of bedrooms j <br /> Character of soli to a depth of 3 feet: f Water.table depth F <br /> SEPTIC TANK O ypelMig Capacity No. Compartments i <br /> PKC. TREATMENT LT ❑ Method of Disposal f <br /> 1 <br /> Distance to nearest: Well Foundation Property Line } <br /> r l.f <br /> k <br /> LEACHING LINE k Cl No. A Length of lines Total length/size t <br /> FILTER BED 4 ❑ Distance 16 nearest: Well Foundation Property Line_ - <br /> i <br /> SEEPAGE PITS mal 1, Depth Size Number <br /> SUMPS �711 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ! ❑ ---have-pre - <br /> �__�r,_done in acc�ordance wqh Sa_ -.. .— <br /> `1"hCertify[hat I pared this application and that the work wiff be n Joaquin county ordinances, stats laws, and <br /> ere <br /> rules and regulations of the San Joaquin county --p y z <br /> Home o ner or licensed agent;_s signature certifies.thajoHowing:-"l.cartity_that in the.performance.of tr w <br /> he_work-fohich,this_permit-is.issued,-1-shall not— <br /> employ A <br /> such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> csrhfle "I cer ify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law ." <br /> VThe appall for all req it inspect' omplete drawing on ver Ida. <br /> k <br /> Title: Date: <br /> Signed <br /> FOR PA �7 <br /> Application Accepted by �t� <br /> �o Area <br /> Pit or Grout Inspection by Date Final Inspection by24T.�� Dat <br /> I <br /> Additional Comments': <br /> I + <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> § j Environmental Health Permit/Services <br /> ' 495 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> E <br /> AMOUNT OtIE AMOUNT EMITTED CK ECEIYED BY OA E PERMIT'N0. <br /> FE <br /> JFIEH I}24IREV <br /> EH 14-M <br />