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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br />' 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> I "F P -0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEM FROM DATE ISSUED <br /> (Complete in. Triplicate) <br /> Application is hereby made to San Joaquin County for a-permit to construct and/or install the voile herein described: This <br /> application is made in cospliance vith San Joaquin County Ordinance No. 5 nd 1 62 and the Rules and Regulations of San <br />!!! Joaquin County Public Health Services <br /> Lot Sime/Acreage <br /> Job Addressrrr-r����/� ` <br /> t 1 Address Pfione <br /> Owner's Name _ 4 (/�� <br /> It <br /> UQC=Q� <br /> ` Phone r � 3Contractor laws eNo <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ) DESTRUCTION ❑ Out Monitoring well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> 14 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> RIndustrial ❑ Open Bottom ❑ Manteca`' - Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack C1Tracy Type of Casing_ Specifications <br /> ublic ""6 n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —.Approx. DeptW'� -l Eastern; /y surface Seal Installed by <br /> Repair Work Done L7 Type Sealing material A Depth of Pump <br /> _ State Work Done <br /> i <br /> Wall Destruction ❑ Well Diameter �_ ( _ 1 <br /> Depth ;tiller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION l I DESTRUCTION I I INo septic system permiltad iI public r is <br /> F available within 200 feet.) <br /> i <br /> Installation will serve: 14-1 <br /> RjdWoncr -.,•Commercial Other <br /> Number of Irving units:_ � Number of bedrooms <br /> F Character of soil to a depth+of Vest: Water table depth <br /> ? SEPTIC TANK 0Type/Mfg Capacity No.,6mpartments <br /> 4*1 <br /> PKG. TREATMENT PLt:"❑ [3 r —Method of Disposal <br /> :-,Distance=to-nearest: Welk: Foundation Property Line <br /> o. iL Len th of lines Total length/size <br /> LEACHING LINE L1 N g <br /> FILTER-BED, 0 Distance to nearest: Well Foundation Property Lina � <br /> �. SEEPAGE PITS l l Depth Sire * Number <br /> SUMPS' 1 .r Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ; <br /> I hereby certify that I have prepared this aQplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> ' rules and regulations of the San Joaquin County i <br /> Homs 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 /> i 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 the following: " rtify th in the performance of the work for which this permit is iso Is <br /> hall employ persons subject workman's compenu <br /> tion saws of C nia." <br /> The app) t m t ull f all r i#llonsV�,nete drawing on r v s' e. <br /> Date- <br /> FOR f"ARTMENT USE ONLY Q <br /> Application Accepted by <br /> Date 65103~l3 Aroe V l <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> Al 445 N Ban Joaquin, P O.Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CCK ECEiVED BY DATE PERMITN0. <br /> 'INFO <br /> -�?- ,f/ i5 <br /> . En1]211REY.ii.s <br /> r <br /> EM t4•2e <br />