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i <br /> APPLICATION FOR PERMIT pp p <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC S A5 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 MAR 1 8 1991 <br /> (209)- 468-3447 ENVIRONMENTAL HEALTH <br /> PT"IT EXPIRE5 I MAR_PBDM DATE ISSUEDPEIRI IT/rSERVjCES <br /> (Complete in Triplicate) <br /> Application is hereby made,to San!Josquin County for a permit to construct and/or install the work herein described. This <br /> application is made in conpliance!vith San Joaquin County Ori rice No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin. County Public Hea th Servi �/�^ t <br /> i <br /> Job Address City Lot Size/Acreage <br /> i — <br /> i?ol "a( <br /> ddrass <br /> f r dr <br /> r't ri�ensC No �" Phone I <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEME T n DESTRUCTION ❑ Out of Service Well D <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE"`--- -;PROBLEM AREA-"CONSTRUCTION SPECIFICATIONS'"- �-= <br /> i n Industrial ❑ Open Bottom ❑ Manteca D"+s. of Well Excavation Dia. of Well Casing <br /> omesticlPrivate 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public (_1 Other © Delta Depth of Grout Seal Type of Grout <br /> 0 Irrigation Approx. Dep h Ea ternit rface Seal Installed by <br /> A9 i- <br /> Repair Work Done 0 Type of Pum H.P.: _ State Work Don s/ <br /> Well Destruction O Well Diameter Seslirag Haterial A Depth <br /> Depth Filler lfaterial k Depth C J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION M DESTRUCTION G lNo.septic system permitted if public sewer is <br /> �- available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other - <br /> Number of living units: Number of bedrooms a�� , <br /> Character of soil to a depth of 3 feet: table depth <br /> SEPTIC TANK. O Type/Mfg r - Capacity No. Compartments <br /> PKG. TREATMENT PLT.L7 i ""'� _ �,,.r" Method of Disposal <br /> Distance to nearest: Well"— Fodhd_ition Property Line , <br /> + \X = <br /> f LEACHING LINE ❑ No. b Len6th of lines '" ^ Total length/slxe <br /> FILTER BED ❑ Distance to nearest: Well{ r FoundationP operty.Line <br /> s" I <br /> SEEPAGE PITS I l Depth Sixe--- Number <br /> SUMPS Ll Distance to nearest: Waif foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> +� *� <br /> 1-hereby certify that I have prepared-this application/and-that_the-work-will be-done.in.accordance-with-San-Joaquin county ordinances,-state laws,-an <br /> rules and regulations of the San Joequiri-Coupty"` <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, l shall not <br /> employ any person in such manner as to becoj^ns subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify thbt 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." i <br /> The appRcan caq f all ed ins ciions. Complete drawing on�rev se :ids: <br /> f Sign Title: Dater <br /> l 1 <br /> - ,FORK EPARTMENT USE ONLY <br /> Application Accepted by Data Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Comments: <br /> omments: <br /> r - <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, "CA 95201 <br /> (((t FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. <br /> ' INFO CASH <br /> + tH 13.24IREV. n51 � , �JJy\ �R �! I�f✓to <br /> EH ti"2e <br />