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APPLICATION FOR PEsRMIT c <br /> SAN 30AQUIN COUNTY PUBLIC HEALTH SERVICES # <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. 9)468-3420 <br /> O HOX2009,TON CAE. , PHONE 095201' -- <br /> I EXP RES 1 YE R FROM D �+ <br /> Complete in Triplicate) <br /> �{ .. 1 or install the work herein described. This <br /> A <br /> anon 1's hereby made!t, <br /> S Joaquin County for a permit <br /> o Oxdinanceaftoru5498and 1862 and the Rules and Regulations of San <br /> app icatioa is made is compliance—with San Joaquin County <br /> Joaquin County Public Health Sei'vlces. \ (l�l� Lot Size/Acreage <br /> �- }]- .�G2. City � <br /> Job AddressT `+ <br /> Phone <br /> ✓� l Address <br /> Owner's Names¢ <br /> j � Yf��C�(,� License No --phone . <br /> �Qr Address <br /> Contractor e WELL REPLACEMENT ❑ ®, DESTRUCTION ❑ Out of Service Well <br /> NEW WELL ❑ OTHER Monitoring Well ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR C] <br /> PUMP INSTALLATION CJrT <br /> SEWER LINES -- DISPOSAL FLO. PROP- LINE <br /> DISTANCE TO NEAREST; SEPTIC TAN K — OTHER WELL _____ - PITS/SUMPS <br /> FOUNDATION _ AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS g <br /> Dia. of Well Excavation <br /> n industrial ❑ Open Bottom ❑ Manteca S � <br /> ❑ Tracy Type of Casing I <br /> C.l Domestic/Private ❑ Gravel Pack t <br /> Depth of Grout Seal T <br /> la Other n Delta <br /> I'1 Public Sud <br /> Seal Installed by <br /> I I Irrigation +. — . Approx. Depth I I Eastern i <br /> Sta ark one W I <br /> Repair Work.Done U Type of Pump — -- Sealing Material & Depth `c r s�Cr7wr. <br /> Weil Destruction © Well Diameter Filler Material & Depth <br /> .. Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION—I ) REPAIRlA I ITION.I I DESTRUGTION 4 I available+wil in 200 fc system eet-1 it public sewer is <br /> Installation will serve: Residence <br /> Commercial Other — <br /> Number of}living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet- Capacity No. Compartments <br /> SEPTIC TANK p Type/Mfg Method of Disposal <br /> aPKG. TREATMENT PLT. ❑ property-Line <br /> r. Distance to nearest: Well <br /> Foundation— «}" <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines : <br /> k FILTER BED ❑ Distance to nearest: � Well <br /> Foundation Property Lina <br /> I Size Number <br /> SEEPAGE PITS 11 Depth Foundation Property Line,__�--.�-- <br /> SUMPS Ll Distance to nearest: Well <br /> DISPOSAL PONDS. ❑ <br /> harsh 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 /> y I y ///{J))} <br /> rules and regulations of the San Joaquin County <br /> ollowing: "I certify that in the performance of the work for which this permit is issued, I she not, <br /> Hams owner or licensed agent's signature certifies the fto <br /> erploy any the person <br /> inn such <br /> l manner as <br /> nity that n theeperfo mance of to <br /> wok for which ethis permit nsation ws issued,s Of fI shall employ personssubjectto workman'sotcompensa <br /> J <br /> g: <br /> tion laws of California." <br /> The applicant t all fo II required inspections. Complete drawing on reVarse si . <br /> Title: Date: <br /> Signed X <br /> ' FOR D E P/j4 RTMENT USE ONL <br /> '+ Date r An <br /> Application;+.Accepted by <br /> Date <br /> C Pit or Grout Inspection by <br /> Date - Final Inspection by <br /> Additional,Comments: <br /> Applicezt - Return all copies to: San Joaquin County Public Health a //Services, environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT REMITTED <br /> CK RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> AMOUNT DUE CASH <br /> a EH 13-24 MEV.I/R 5) <br /> EK 14-2e i <br />