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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 /> P O BOX 2009, STOCSTON, CA 95201. p "'IN <br /> r <br /> r 447-" <br /> T E%PIRES YE FROM DATI;Ijfl ����ti�4�r �Co" <br /> 19�� <br /> (Complete in Triplicate) ��y �� Pl//Cr <br /> Application is hereby mmde,to San Joaquin County for a permit to construct and/or install the vork herein describe d.t•/1'hi's <br /> applicstion is made in compliance vith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and ftegulatione of <br /> Joaquin County Public Health services. <br /> City Lot Size/Acreage <br /> E .fob Address <br /> Address PtT�I — Phone <br /> Owner's Name <br /> r ? <br /> C �„ Address �3 � License Na. (Phone <br /> Contractor <br /> OF WELL/PUMP' NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION Cl Out of service Well <br /> TYPE <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> OTHER O 1 Monitoring Well n <br /> DISPOSAL FLD. PROP: LINE i <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES E r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> —�-�-- Dia. of Wap Casing <br /> 0 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specific <br /> Type of Casing_ ations <br /> Domestic/Private O Gravel Pack ❑ Tracy Type Of Grout r4 - <br /> I"i Pubkic I"1 Other Cl Delta Depth of Grout Seal <br /> I 1 Irrigation �.Approx. Depth I I Eastern <br /> Surface Soul installed by i <br /> State Work Done <br /> Repair Work Done U Type of Pump vvM•P• ; i <br /> tt -_Sealing Material A Depth <br /> WeN Destruction ❑ Well Diameter a <br /> Depth i FiAiEr Material a-Depth-- <br /> ! stem PO <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAfRIADDITION l I DESTRUCTION I 1 available wiic thin 200 feell.4 if public sower is <br /> i � d <br /> t Installation will serve: Residence 1 Gommefcial Other F i <br /> F Number of living units: Number of bodrooma # x + <br /> f Character of$ON to a depth of 3 fest: Water table depth# <br /> No. Compartments <br /> SEPTIC TANK. O Typal Mfg Capacity <br /> E i - -- -----�-- Method of Disposal ' <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest:i Well Foundation Property L / <br /> Total length/size <br /> LEACHING LINE Cl No. I!+ Length of lines Y� <br /> FILTER BED ❑ Distance to nearest. well _i ;Foundation i <br /> Property Line r <br /> i ,� _ •--� Number <br /> SEEPAGE PITS I I Depth =size <br /> SUMPS LI Distance to nearest. Well Foundation Property Lina <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that i hove prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner of licensed agent's signature certifies the following: "I certify that in-the performance of the work for which this permit is issued, E"I not <br /> amploy any person' such manner as to become subject to workman's compensation laws of Calilornia."Contractor's hiring or subcontracting signature <br /> certifies the folb • -I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa <br /> tionlaws of CANIVIL-111111.1. <br /> The =icon call for ell requ' inspe . <br /> ction Complete drawing o rev r side. <br /> S. nod Title: ,C Date: <br /> W r <br /> FOR DEPARTM USE ONLY <br /> Application Accepted by Data Area <br /> Dat�� e1/11Z , <br /> Pit or Grout Inspection by Date — Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: Ban Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEE) RECEIVED BY DATE PERMIT'NO. <br /> INFO [p�I �y <br /> . EH 13-24111EV.IJK P. q O� <br /> EH 1440 <br />