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APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT <br /> s ENVIRONI[ENTAL WRAITH DIVISION ����@�,EVE� <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 NOV C <br /> P O BOX 2009, STOCKTON, CA 95201 3 1992 <br /> SAN JOAQUIN COUNTY <br /> PERMIT EUIRES 1 YEAR FROM DATE ISSUED p;�g�;C-HEALTH SERVICES <br /> (Complete in Triplicate) ENVIRONIMENTALHEALTH,D1Vic;Or• <br /> Application is hereby.sade,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made is compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> ^ ' Joaquin. County Public Health Services. <br /> 8010 1r1 TThJ City Lot Bite/Acreage <br /> E- <br /> Owner'sName Address )Phone <br /> Contractor Address6. <br /> i License No..Q� --Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> - PUMP If�i,STALLATipN ❑ ;SYSTEM"REPAIR OTHER ❑ Monitoring Well_ ❑ <br /> �DISTANCE-TO NEAREST:''SEPTIC TANK �� SEWER LINES!! DISPOSAL FLD. - PROP. LINE t, <br /> FOUNDATION AGRICULTURE 1NELL, OTHER WELT J` PITS/SUMPS—_ A �( <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION r <br /> C) (Industrial O Open Bottom. ❑ Manteca,Via. of Well Excavation Dia. of Wait Casing <br /> D4 <br /> Domestic/Private Ci Gravel Pack��C] Tracy;a, Type of Casing_ Specificatkxu <br /> I'I Public f n Other —ti'Fl Delta Depth of Grout Seal Type of Grout <br /> I I Irripallon•i,r,:1" �•Approx%Depth ( I I Eastern Surface Seal Installed by <br /> Repair Work Dori&" U Tvpeo f'umlp H.P. ` ' ' State Work Dona <br /> Well Destruction '—.p/Well Diameter S-11n.B Material'i Depth <br /> /Well <br /> ! Q• tiller Material i Depth <br /> TYPE OF SEPTIC WOR NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> %-^-'. r , available within 200 feel.} <br /> installation will terve: Residence Commercial_ Other l <br /> Number of living units: Number of bedrooms <br /> Character of soN to a dspth of 3 feat:. � Water table depth <br /> SEPTIC TANK. O Type/Mfy Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Fpundeiion Property Line <br /> LEACHING LINE Cl No. A Length of lines Total length/size <br /> FILTER OED 0 Distance to nearest: Weill Foundation Property Lina <br /> SEEPAGE PITS I I Depth Size Number <br /> -SUMPS LI Distance to neerest:_ WeN. FdunBation - .Property-Line, - <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 laws, and <br /> ..--� rules and regulations of the Sen Joaquin County <br /> I <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any per"n such manner as to,become subject to workman's compensation laws of California."Contractor's hiring or sub-contrecting signature <br /> certifies the f :,.I certify that in this performance of the work for which this permit is issued,I shall employ persons subject to workman's compenaa- <br /> tion laws Ca <br /> TM applies t call for aN r' sd iii 'ons. Complete drawing on reverse side. <br /> Signed - Title: pate:' <br /> f FOR IDEPAFITMEN9 USE ONLY It <br /> Application Accepted by - Date 'Area <br /> Ph of Grout Inspection by � Date Final Inspection by pets <br /> V <br /> S <br /> Additional Comments: <br /> i <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Havironmental Health Permit/Services <br /> 445 N SAA Joaquin, P 0 Boa 2009, Stkn, OA 95201 <br /> FEE OU T DUE = AMOUNT REMiTTEO x ECEIV 0 By ATE PERMfT'ND. <br /> EM 13-24 IREV.r ti el ✓ 4 6,/" <br /> h <br /> EH 14.26 <br />