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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468--3420 <br /> P O BOX 2009 TOCKTON, CA 952014 <br /> I` <br /> PERMIT EXPIRES 1 YEAR FROM D <br /> (Complete in Triplicatedc <br /> Application is hereby made.to San Joaquin County for a permit to c � 7' ThiE <br /> application is made in compliance frith San Joaquin Count 'Ordinance 3T0. 51an"?1"`1tS��i1 `ltia g� �� �t <br /> Joaquin County Public Health Services. <br /> Job Address 7Y� �'/ - City - Lot Size/Acreage /�• <br /> Owner's Named — Address Phone <br /> Contractor Address License No, 17,f Phone 36 c3f& <br /> TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F7 DESTRUCTION ❑ Out of,Service hell ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <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 4. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing <br /> (:l Domestic/Private ❑ Gravel Pack• El Tracy Type of Casing_ Specifications <br /> I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I ltdoation —Approx. Depth I 1 Eastern Surface Seal installed by <br /> -Repair Work Done . 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material i Depth <br /> ; <br /> Depth Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION W-DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will servo:' Residence Commercial Other 4 <br /> Number of living units: Number of aoms <br /> Character of soil to a depth of 3 feet: Water`isbla depth <br /> SEPTIC TANK. i3—Type/Mfg ' Capacity Na. Compartments 2- <br /> PKG. TREATMENT PLT.O y _ -- Method of, � <br /> Disposal <br /> Distance to nearest: Well 7G�7F_0 <br /> oundation Property Line f <br /> LEACHING LINE [ /filo. III Length of lines .V Total length/size <br /> FILTER BED O Distance to nearest: Well �t Foundation_e2-S' <br /> _;_ Property Line I] <br /> SEEPAGE PITS Iq-Depth 5 " Size {� Number <br /> f <br /> SUMPS LI Distance to nsarost: Well 1,8,01 - Foundation Q Property Line - <br /> DISPOSAL PONDS O <br /> I hereWconify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> iulas and regulations of the San Joaquin County <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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."-Contractor's hiring or subcontracting signature <br /> cortifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant call for all r trod i coons. Complete drawing on reverse side. 7 <br /> - ...Date: <br /> Signed - _ Title-, -- <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ft Grout Inspection by Final Inspection by Date <br /> y <br /> 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 0 Box 2009, Stkn, CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA RECEIVED BY ATE PERMIT'NO. <br /> INFO 41 <br /> O <br /> . EM 13-24IREV.1/%51 W i t0-b <br /> I �H 14Qa 7;E_ <br />