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APPLICATION FOR PERMIT <br /> SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 <br /> r ,• +ir ' <br /> ,I REMIT .E%PIRES 1 YEAR SROM DATE} jSSUM <br /> (Complete in Triplicate) <br /> Application is hereby made to Stan Joaquin County for a permit to construct tend/or install the J �teNL_ 'scribed ,,,Th!44 <br /> applicatiao Is made in ccap'liance with San Joaquin County Ordinance No. 51+9 and 18b2 and th + Ifl l,t ui ilo4ta of $an <br /> 11 <br /> Joaquin County Public Health services. <br /> Job Address 016 <br /> City Lot Size/Acreage.. <br /> Owner's Name dress w Phone } <br /> Conttac Addre License N ,S Phone `� <br /> TYPE Of WELL/PUMP. NEW WELL ❑ WEGC REPLACEMENT 71DESTRUCTION Li out of Service Well LI <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ Monitoring Well C1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION AGRICULTURE WELL - OTHER-WELL— <br /> PITS-/5L11iAP5 <br /> "INTENDED I.AE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> to <br /> Indus al C1Open Bottom ❑ Manteca Dia, of Well Excavation mDia, of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications— -- <br /> ❑ Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> M Irrigation Approx.' <br /> pprox. Depth ❑ Eastern uriace Soul Installed by <br /> Repair Work Done W Type of Pump 64 H.P. L �— t State Work Done <br /> Well Destruction © Well Diameter Sealing Material i Depth <br /> ' - <br /> P111er Material & Depth <br /> DepthI <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION 0" REPAIR/ADDITION DESTRUCTION CI (No septic system permitted if public sewer is <br /> I Iavailable within 200 feel.l CY) <br /> Installation will serve: Residence� Commercial---- Other' <br /> 3 t v_I <br /> Number of living unite Number of bedrooms <br /> Character of soil tp a depth of B feet: t i c `` ` 4 Water table depth 4 _ v <br /> SEPTIC TANK rtw u�❑ t�Type/Mfg+ ry _��`� �-'�'� { �'� �`rapacity No, Compartments � <br /> r PKG TREATMENT,PLT:❑ ,, t ;} r µl ' ,.,, t ; y: x i' Method of Disposal '- E - En r" <br /> t`. -. >.E:. Distance to nearest: Well Faundat�on '+ f'ropeny,line' L <br /> 25 1992 <br /> LEACHING LINE 0 No. & Length of lines I Total length/size v ! -.,'T , , ' ?- <br /> FILTER SED t_I Distance to nearest: Well Foundation Property Line __ �r �trENTMI MP&P., ply" I9IN <br /> SEEPAGE PITS t I Depth Sire f Number <br /> SUMPS Ll Distance to nearest, Well Foundation Property Line <br /> DISPOSAL PONDS D <br /> I hereby cenify 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 t <br /> Home owner or licensed agent's signature certifies the following: "I comity 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 certify that in the performance of the work for which this:permit is issued, I shall employ persons subject to workman'&compensa- <br /> tion laws of California." +. } <br /> The applicant must a to Mo drawing on rs se side. <br /> Signed X Title: Date: <br /> „ t <br /> FOA DEPARTMENT 13SE ONLY <br /> r � <br /> Application Accepted by F Date Area r, <br /> i r aLS 9y <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> n 51 <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 HQX.2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVEq 9Y DATE PERMIT NO. <br /> INFO <br /> • EH 13.24 IREV.t/MSI — �ov Tom+' 4i1-­i- <br /> EH <br /> O`er f <br /> ` -:i„ <br /> EH 111.7E <br />