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APPLICATION FOR PERMIT <br /> SAN JOAQUIN. COUNTY PUBLIC HEALTH SERVICESi. <br /> ENVIRONMTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 k.o- <br /> tP O BOX 2009, STOCKTON, CA 95201 <br /> �. <br /> ' <br /> PERMIT E%PIRES 1 Y FROM D T S <br /> (Complete in Triplicate) <br /> in <br /> Application <br /> is hereby <br /> nmade. <br /> lia ce vSan lthui CJ�quinoCounr a ty Ordirmit trtsncenNo 51+9struct aando1862sand thstall eRules andvork eRegulationedof San <br /> e <br /> application San y � <br /> Joaquin County Public Health services. } 1 <br /> Lot Size/Acreage ET <br /> C;ry <br /> Job Address <br /> Owner's Name <br /> �� � Address :5Z <br /> Phone <br /> Contractor I�� Address License No.WELL REPLACEMENT REPLACEMENT ❑ DESTRUCTION ❑ Out or service Well ❑ i <br /> TYPE OF WELLIPUMP: ��I NEW WELL Monitoring Well O <br /> PUMP INSTALLATION E)SYSTEM REPAIR OTHER ❑ <br /> f DISPOSAL FLD. PROP. LINEt <br /> DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES <br /> FOUlJDATION AGRICULTURE WELL """� OTMER WELL PITS/SUMPS !� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS. <br /> Die. of Well Casing !_ <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> 'OomesticlPrivata Gravel Peck /I Tracy Type of Casing_. ` f I <br /> Delta Depth of Grout Seal Type of Grout <br /> l'1'Public 1-1 Other � <br /> Q <br /> I Idrripation 1p�o�UePth I I Eastern Surface Seal installed by <br /> Repair Work Done L7 Typa,of Pump H.P. State Work Done <br /> " Sealing Material i Depth <br /> 1 Well Destruction ❑ Well'IDiameter vier Material i Depth <br /> Depth [ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I <br /> DESTRUCTION I aNaitablehwithin 20stem feet-1 <br /> ted if public sewer is <br /> � ..„ ......... II <br /> Installation W serve: ' Residence — Cnmmsrcial--.Other <br /> Number of living its: i�. Number of bedrooms <br /> A. r <br /> Character of BON to s th of 3 feat: Water table depth <br /> SEPTIC TANK. O /Mfg Capacity""" No. Compartments <br /> Method of Disposal. <br /> PKG. TREATMENT PLT. ❑ �. <br /> Distance.to nearest:' Well Foundation; Property Line <br /> .4- total length/sire <br /> LEACHING LINE 0 No. 6 Length of finis—-"-_ r <br /> FILTER BED Q Distance to nearest:': Wall Foundation Property Lina <br /> SEEPAGE PITS 11 Depth rsi:z' � 'Number t <br /> SUMPS <br /> CI Distance to rlsarest: Well Foundation .-Property Line <br /> DISPOSAL PONDS ❑ <br /> ' n and that the work will be done in accordance with San Joaquin county ordinances, slatws, and <br /> I hereby certify that 1-have prepared this applicatioY <br /> rules and regulations of the San Joaquin County, <br /> f Home owner or licensed agent's signature certifies the followr sub contracting signature <br /> ing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> ` employ any person in such manner as to become subject to woikmaWs compensation laws of California,'.' Contractor's hiring oW <br /> candies the following: 1 unify that in the Performance of the work for which this permit is issued, I shall-employ persons subject to workman's compensa- <br /> tion Is of California/'' <br /> The applicanr�equ' tions Complete drawing on reverse side. iso If� <br /> Signed Title: Data: <br /> Aw <br /> FOR DEPARTMEf11T USE O LY � 7"1 i <br /> II Data Area <br /> Application Accepted by r �. ✓i <br /> ' a Data z z' <br /> Pit or Grout Inspection by Dais 1 11 Final Inspection by <br /> ' 'Addiiionat Ci�rrirrisntr + i <br /> Vr <br /> I' <br /> Applicant - Return all opies o: San Joaquin County. Public Health Servic I <br /> I� Snvri3ilmental'.,Healtll Permit/Services <br /> li 445 N°Siin:'Joa" in, P O Soli-2009, Stkn, GA 95201 <br /> FEE AMOUNT DIE AMOUNT REMITTED CK RE EIVED BY DATE PERMIT N0. <br /> INFO �. <br /> EH 14-28 '` •✓ C/� <br />