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:i <br /> APPLI CATI ON FUR PERM I T <br /> A <br /> � c SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Irl( <br /> + a ENVIRONMENTAL HEALTH DIVISION <br /> 445NSAN JOAQUIN, PHONE 2009 420 <br /> , STOCKTON, CA P 0 BOX �tGl� <br /> PERMIT EXPIRES 1 YEAR FNM DATE ISSPED <br /> (Complete in Triplicate) <br /> Application is hereby made to San .Toe'uin•'-)unty for a permit to construct and/or install the work herein described. This <br /> application is made in,ecMllance�wRL4 :.aquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County P�:"^ :i'ami,.►`^ervice ,,C , <br /> Job Address " l,e ' �' !_ l~ Lot Size/Acreage <br /> Owner's Name Address ��!r0^e <br />'t i <br /> t p� Wcense No. 2 Phon - <br /> 37 <br /> TYPE Of WELL/ UMP: NEW.WE k WELL REPLACEM T n DESTRUCTION ❑ Out of Service hell ❑ <br /> `" y _PUMP 4NSTALLATION:-❑. ---SYSTEMAEPAI OTHER C] Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C! Industrial ;p ❑ Open Bottom CI Manteca Dia. of Well Excavation - Dia. of Well Casingx <br /> . k -_ <br /> (:4 Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ SpecificaC <br />{ I't Public Cl Other [l Delta Depth of Grout Seal T• ' of Grout <br /> irrigation —Approxi 0 I Eastern Surface Seal installed by <br /> Repair Work Done U Type of Pump P. Stats Work Don <br /> ILI <br /> Sealing (Material i Depth <br /> Well Destruction11 <br /> ❑ Wall Diameter v <br /> Depth Filler Material•A-Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> 1 i. availabl"shin 200 feet.1 440 <br /> Installation will serve: Residence ti Commercial's Other <br /> Number of living units: Number.of bedrooms <br /> Character of soil to a depth-of I-fest: ' Water table depth <br /> �� ❑'- Typo/Mf Capacit No. Compartments <br /> SEPTIC TANK.; ��- g! _ Y <br /> PKG. TREATMENT PLT,❑ Method of Disposal P <br /> r Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. S Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> t-N`umbart ""`_""`R...�..�...�►- <br /> :aSUMP.SLI..sOistartce,to,naarost:��:�Wejl=��Foundati`on_. <br /> DISPOSAL PONDS ❑ /^ )l •- 1 <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 San Joaquin County <br /> i <br /> Home owner or licensed agent's signature certifies the following: "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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I ity that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- <br /> tion tawsof Calif No.' t <br /> The applican m call ed in tions. Complete drawing on re seslde. <br /> Title: r Date: <br /> Sig <br /> 1 - <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by " Date res <br /> ale <br /> Pit or Grout Impaction 'Date Final Inspection by Data ! <br /> E - <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> j Environmental Health Permit/Services <br /> E 445 N San Joaquin, P O Box-2009, Stkn, OA 95201 <br /> i FEE I AMOUNT OUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EK 13-24 INFO /7y) ,y`/�/� 1 7 <br /> EN 14•ffi TREY.t i g Ol ��►W L V �.t7f� 1971" 1 ^�r ^ <br />