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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY pUBLIC EALTH SERVICES <br /> ENVIRONMENT <br /> ON <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERM T ESP I RE S 1 YE FR M. D T'E ISSUED <br /> i (Complete in Triplicate) <br /> Application is hereby,made,to Bea Joaquin County for a permit to construct and/or ins tell the workRules <br /> herein described. s <br /> application is made in ceetpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of ban <br /> Joaquin county Health Bervi qs <br /> SSity Lot Size/Acreage <br /> Job Address �. <br /> �- � Phone <br /> e Address —7 C7f <br /> 0 nor 6 Nam cense No. Phoner r�Z <br /> a ra or . DESTRUCTION Cl Out of Service well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEME T C] i4onitoring Well ❑ <br /> SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION ❑ / <br /> E SEWER LINES �-- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �—�--- AGRICULTURE WELL OTHER WELL_. - PITS/SUMPS <br /> FOUNDATION i <br /> INTENDED USE TYPE OF WELL PROBLEM EA CONSTRUCTION SPECIFICATIONS Dia of Wa1kYCasing <br /> ❑ 1 dustriel ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications ,f' <br /> r ❑ Tracy Type of Casing_ <br /> { ptestic/Priva[e G� Gravel Pack Depth of Grout Seal <br /> Typo of Grout <br /> I'1 Public 1 1 Other C'1 Delta <br /> I I Irrigation �.Approx. Depth I I Eastern Surface Set' kn�'��+s_Q , T <br /> - p a <br /> Repair Work Done LJ Type of Pump H.P. <br /> Sealing <br /> Well Destruction O Well Diameter Filler Naterial-6 LepLh �' <br /> ` Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 fiEPAIRIADDITIDN I I DESTRUCTION l( fvailable'wthin 200leeLl d'if public sewer is <br /> F { <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms 4 t �.y t <br /> z Water table depth <br /> Character of aaii to■depth of 3 feet: No. Compartments I <br /> Capacity <br /> SEPTIC TANK. © TypelMig Method of Disposal r <br /> PKG. TREATMENT PLT. ❑ 3 <br /> Distance to nearest: Well. Foundation Property Line <br /> Total length/sire+ � <br /> 1 LEACHING LINE Cl Na b Length of lines Property-Line t <br /> FILTER BED ❑Distance-to nearest: well y Foundation ; <br /> iI Number <br /> I I Depth Size <br /> SEEPAGE PITS 1 <br /> dwell, Distince to rlaaresti Well } Foundation - Property Line <br /> SUMPS - - I <br /> DISPOSAL PONDS.. XO ' <br /> I hereby certify that 1-6-no prepared this application and that the work will be done in accordance with San Joaquin county ordinances, erste laws, and <br /> i rules and regulations of the San Joaquin County <br /> following: "I certify that in the performance of the work for which this permit is issued, k shall not <br /> Home owner or licensed agent's signature certifies;the <br /> employ any person in such manner as to become subject_to-workman'.s.componsation_laws.of-California.;;,,.Contrector-s.hiring.or,sub-contracting signature <br /> { certifies the following: "I unity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's eampensa <br /> tion laws of California." <br /> `The applica t call for fired 'napections. Complete drawing on r arse side. <br /> TIN Date: <br /> Sig <br /> FOR DEPARTMENT USE ONLY a <br /> Date <br /> r� Area <br /> Application Accepted by <br /> PN or Grout Inspection by <br /> Data -- Final Inspection by Oats T 9 <br /> Additional Comments: <br /> .Applicant --Return all copies o: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P-O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMIT;Ae- <br /> CASH ti- <br /> INFO j� <br /> . EN 13,24(REV.IIK51 fQ " 76a 07 <br /> EH 14.16 <br />