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APPLICATION FOR PERMIT <br /> 40 SAN JOAQUIN COUNTY PUBLIC HEALTH SgRVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> p O BOX 2009, STOCSTON, CA 95201 <br /> F I <br /> IT EXPIRE 1 Y FR M D E <br /> (Complete in Triplicate) <br /> Application is madeDin compliio an ec with Son Joaquino <br /> oCounty ordinancenNo. 549 ando1862aand theeRules andeRegulations Of SanThia <br /> application <br /> is Joaquin County Public health Services. <br /> / City LOA Lot Size Acreage <br /> F <br /> Job Address I <br /> Phone <br /> Address Si4 sy1 <br /> Owner's Name <br /> License No. Phone <br /> �, ldcAd <br /> ws7 Address -Z <br /> Contractor � DESTRUCTION ❑ <br /> TYPE f WELL/PUMP: NEW. ELL-0— 0 Out of Service Kell ❑ <br /> OWELL REPLACEMENT monitoring Well ❑ <br /> _ � SYSTEM REPAIR OTHER ❑ <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 PROf3LEA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C3Open Bottom,., ❑ Manteca Dia. of Well Excavation <br /> C7 industrial <br /> � ❑ Tracy Type of Casing_ Specifications <br /> [a Domes6C1Priv8te I-) GravelPack ' Depth al Grout Seal Type of Grout <br /> [1 Other ' fl Delta <br /> I'3 Public , <br /> i I Irrigation w.Approx. Depth l I Eastern Surface Seal Installed by <br /> of Pump H.P. <br /> State Work Done, <br /> Repair Work Done U Type Sealing lfaterial & Depth <br /> Well Destruction ❑ Wail Diamets, liber Material i Depth <br /> z Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION -REPAIRIADDITiON I--I,-•DE5TRUC T71ON�-1-6-aNailabislw Thin yQstem p}�t�jed i! public sevrer is <br /> - s � �X+t sr-.a✓� Gar P�'.��� �-� i9yz <br /> Instailation will serve: Residence <br /> Commercial Other's-- <br /> Number of Irving units: Number of bedrooms .3 <br /> k ! C& te <br /> War table depth <br /> Character-of soil to a depth of 3 feet: - �Sl :No. Compartments - d <br /> SEPTIC TANK. ❑ Type/Mfg _ - Capacity - / <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ A <br /> Distance to nearest.,�We1l Foundation Property tine <br /> ff 4 1 ' <br /> L Notal length/size <br /> , <br /> I LEACHING LINE No. & Length of lines „— <br /> ' Foundation .- Property Line <br /> i FILTER SED ❑ Distance I o nearest: Well�X z� <br /> Jbr .. . , <br /> � :0'°� Number <br /> ( SEEPAGE PITS l Depth's Size <br /> - Property Line 7 S <br /> F SUMPS LI Distance <br /> to nearest: Well /Od,` Foundation' L�-- <br /> i <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances. state <br /> rules and regulations of the San Joaquin County Y <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 /> t to workman's-compensation laws of COMOFnia.„Contractor's hiring or sub-contracting signature <br /> employ any person to such manner as to become wbpe <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 o1 California." <br /> The applicant most cell for all required inspections. Complete drawing on reverse side. <br /> I 11 , /) - <br /> Title: - Date: <br /> Signed )� <br /> FOR DEPARTMENT USE ONLY �J _ 1 ,� <br /> Date q/— Area <br /> Application ACCepted by <br /> &or Grout Inspection by d <br /> DateFinal Inspection bye Data <br /> Additional Comments: <br /> Applicant - Return all copies-to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE K RECEIVED 9Y DATE PERMIT'NO. <br /> {NFO AMOUNT DUE AMOUNT REMITTED C SH <br /> . EMI 24(REV.1)%51 �(l y/�U i/J� /�U`-' <br /> EM 14.20 <br />