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APPLICATION FOR PERMIT <br /> 3 . <br /> TH <br /> SAN jOAQUIN COUNTY PUBLIC <br /> ENVIRONMENTAL HEALTH SIV S ON SERVICES <br /> W l_ <br /> 1601 P 0 BO% 20091,VSTOCKTON, CA095201+3420 <br /> I <br /> P - <br /> _aE <br /> Egp RTS 1 YEAR 'FR MDA E <br /> - (Complete in Triplicate) <br /> permit to constructga��a°1862stall end thee work Rules andei. <br /> RegulationsdOf Sans <br /> Application is hereby made,to San Joaquin County for a P Ordinance No. 5 <br /> lienee with San Joaquin County <br /> application is adelinHeolth Services. f 6) fir. 4 <br /> Joaquin County f Z OC) Lot Size/Acreage <br /> r�f City <br /> Job Address Phone <br /> , <br /> Address <br /> Owner's Name �; jF 2_ phone_ <br /> t0 L{. i.v vU ` License Ko. <br /> Address DESTRUCTION ❑ Out °f Service Well �) <br /> Contractor % `" f f WELL REPLACEfVIENT fa Monitoring Well'` �� <br /> NEW WELL OTHER ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR D PROP LI <br /> PUMP INSTALLATION DISPOSAL FLD. <br /> NE <br /> �` <br /> SEWER LINES ----�' OTHER WELL_-- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL <br /> FOUNDATION' <br /> TYPE OF WELL .PROBLEM AREA -CONSTRUCTION SPECIFICATIONS Dia of Well Casing 1 <br /> INTENDED USE N �❑ Mant"ace O'a. eAavavon Specifications <br /> pen Eotto Y 1 �`�. � . <br /> ri Industrial (] Tracy Type of Casing„ <br /> ❑ Gravel Pack Type of Grout r� <br /> [;I,eomesticlPrivate alta Depth of Grout Seal r <br /> I public 2 "' Surface Seat Installed by <br /> I I Irrigation7�.Approx. Depth I Eastern State Work Done <br /> Of Pump H.P. ---� <br /> r <br /> Repair Work Done 0 Type terial & Depth <br /> Well Destruction ❑ Well Diameter Fieterial & Depth <br /> Depth U `7 LA <br /> lavailable within 200 feet.) <br /> I TYPE OF SEPTIC WORK; NEW INSTALLATION Ii REPAkRIADDI7tON I 1 DESTRUCTION 4 1.allo septic system permitted-il public sewer is �J <br /> Commercial_•.� Other'____ � 'F <br /> t . Installation will serve: Residence, r <br /> E � ] Number of bedrooms�� Water table did th C <br /> i Number"of living units: <br /> �l <br /> Character °t soil to a depth of 1?eet: Capacity No. Compartrr <br /> b d Typi!M#g r <br /> SEPTIC TANK. Method of Disposal ` <br /> d .� <br /> PKG. TREATMENT PLT. C1 Foundations operty Line---� <br /> Distance to nearest: Well <br /> I . <br /> } Total lei gthlsize <br /> LEACHING-LINE ❑ No. & Length of lines Foundation _ �--- Property Line ---- <br /> FILTER BED ❑ Distance to nearest: Well <br /> Numb f <br /> SEEPAGE <br /> ` PITS I I Depth Size Foundation Property Line f-- <br /> ___.�.--- <br /> SUMPS LI Distance to nearest: Well �� <br /> DISPOSAL PONDS <br /> ' certify that I have prepared this applicatign and that the work will be dans in accordance ith San Joaquin county ordin <br /> hereb ances, state laws, and <br /> 1 Y <br /> rules and regulations of the San Joaquin County I certify that in the performance the work for which this permit is issued, I shall not <br /> I Horne owrier or licensed agent's signature certifies the following: " <br /> performance of the work for which this permit is issued, 1 s all employ persons subject to workman's compensa- <br /> employ any person in such manner as to become subject to workman's compensation laws of CaGfor ia." Contractor's hiring or sub-contracting signature <br /> certifies the following. "l certify that in thepe <br /> j tion laws of California." <br /> ,.1 <br /> The applicant must call for all squired inspections. Complete drawing on reverse side. Date. <br /> Title: �"^r�' <br /> ' Signed X__ <br /> FOR DEPARTMENT USE ONLY <br /> Date i 10 Area <br /> l Application Accepted by Gv`" Date <br /> I Pit or t Inspection by Final Inspection <br /> Date ction by <br /> 4 <br /> Additional Comments: Public Health <br /> Applicant - Return all copies to: San Joaquin County <br /> ,.} Services, Environmental Health Permitstocitton� CA 95201 <br /> f 11 1601 E. Razeltod Ave., P 4 Box 2449, <br /> CK PATE PERMIT NO. <br /> T REMITTED CASH �-7W <br /> AMOUNT RECEIVED BY <br /> FEE AMOUNT DUE <br /> I INF <br /> � <br /> � 1117�� <br /> . EH 13-24I11111/a51 <br />