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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLICHEALTH <br /> SERVICES A10 6v <br /> HDIVISION <br /> ENVIRONMENTAL S <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 N O G <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM T EXPIRES 1 YEAR FROM D TE IM-0— <br /> (Complete in Triplicate) <br /> vork <br /> in <br /> tall <br /> Application is hheerrebyR3"ee.to compliance Von uin G��quinoCounr a ty a dirmit tnaacenNo. 549 and struct o1862eand the Rules and eRegulationsdof San <br /> Ith San $ <br /> application is <br /> Joaquin County Public Health Services. , <br /> ir �G",� `�. City Lot Size/Acreage <br /> Job Address ! <br /> Phone <br /> rh•� Address <br /> Owner's Name _ <br /> Phone r <br /> Contractor <br /> Address' t `r[ �j License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C) OESTR`IJCTION";=1`Out Moa toring well c3 <br /> OTHER ❑ <br /> PUMP INSTALLATION-Q <br /> SYSTEM REPAIR Q . <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> 1--INTENDED-USE-"""'"--TYPE OF'WELL = PROBL�EA-00 N STA UCTION-SPECIF I CATIONS Dia. of Well Casing <br /> LC, Industrial 0 Open.Bottom 0 Manteca Dia. of Well Excavation Specifications <br /> Type of Casing_ <br /> Ul <br /> 17.1 Domestic/Private 0 Gravel Pack n pelta❑ Tracy ° Depth of Grout Seal Type of Grout <br /> I'1 Public [a Other <br /> 1 I Irrigation ___ Approx. Depth I 1 Eastern Surface Seal Installed by <br /> H P State Work Done _ <br /> Repair Work Done L7 Typa of Pump Sealing Material a Depth <br /> Well Destruction D Well Diamaterf hiller Material i Depth G` <br /> Depth _ _ -- "-- rmitrad it public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I II REPAiRlADOITION l I DESTRUCTION ptic system pa <br /> t , � available within 200 feet.) <br /> Installation will serve: Rosi ncet_� Commercial Other- -- <br /> Y (� <br /> Number of living unity. Number of bedrooms t Water table depth <br /> Character of sol{to a depth of 3 feet: V yNo. Compartments <br /> SEPTIC TANK 0 Type/Mfg' Capacity---- <br /> _ - Method of Disposal � �} <br /> PKG. TREATMENT PLT.© " v <br /> property Line <br /> Distance to nearest: Well Foundation —�- — <br /> I <br /> Total lengthlsize <br /> LEACHING LINE ❑ N6:`t9-Length of lines ToPro rt Lina . <br /> I FILTER BED DD—istance to Tnsarast: Well Foundation Property <br /> ! f <br /> Size Number <br /> SEEPAGE PITS 11' .Depth Property Line <br /> SUMPS L1,_,pistanos to nearest: —=Foundation <br /> DISPOSAL PONDS © T <br /> I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulatiom of the San Joaquin County <br /> llowing: "!certify that in the performance of the work for which this permit is issued, I shell not <br /> Horne owner or licensed agent's signature certifies the fo <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:111 certify that in the performance of the work for which this permit is issued. I shall employ persons subject to workman's compenss- <br /> tip of California.':. T . <br /> The•applican t ca dor i s ti s. mple -drawing on jverse.sid <br /> Title: l/��2f' Date. C 1 <br /> Sig <br /> F DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout inspection by <br /> Date_ Final Inspection by Date <br /> j Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box-2009, Stan, CA 95201 <br /> FEECAK RECEIVED BY jDATE PERMIT'NO. <br /> IEEE AMOUNT DUE AMOUNT REMITTED SH <br /> . NFO <br /> EH 1b21 rREV.I/ti 51 � . <br /> -J �rn� �oa L 92--.399 <br /> EH 14.26 <br />