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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> TT EICPIRIma 1 YEAP PROM PATH ISS-MAN <br /> (Complete in Triplicate) <br /> Application in tall <br /> work <br /> in <br /> application is made in compereby liance wSan ithuin SanCounty Joaquinor a County Ordinancermit to nstruct NO. 549aando1862sand the Rules aadeRegulationsdof Bang <br /> Joaquin County Public Health Services. <br /> -3 S q �,q In J o wq City s Lot Size/Acreage <br /> Job Address <br /> �Ac� Address $/® CARD �{- C J P Phone <br /> Owner's Name Dnl 7s <br /> Contrattof fi=g VD GJOaD -Address �✓ 954- <br /> E License No. �jyy7L Phone d3 397 <br /> TYPE Of WELL/PUMP. NEW WELL Cl WELL REPLACEMENT 0 DESTRUCTION 0 out of Service well C1 <br /> _ Monitoring Well <br /> PUMP INSTALLATION fa SYSTEM REPAIR 0 OTHER O <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 /> In Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> U Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications. - <br /> M Ptlblic I_l Other IJ Delta Depth of Grout Seal Type of Grout_ - <br /> G Irrigalion — Approx, Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done _ 0 <br /> Welt Destruction ❑ Well Diameter Sealing Material i Depth <br /> Depth Filler Material 4 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION X REPAIR IADDITION M DESTRUCTION M a�vo septic <br /> lable system <br /> m emitted if public sewer is <br /> Installation will serve: Residence Commercial_,.,. Other C0)rl, ?41 All;-'0 feet.1 <br /> /4 7Z�e <br /> Number of living units: .. Number of bedrooms <br /> Character of soil to a depth of 3 feet: ,1-A y Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity 1600 No. Compartments <br /> PKG, TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: Well ^A,00Foundation _-S ' Property Line <br /> LEACHING LINE M No. b Length of lines I — k®" Total lengthlsixe /Sb ` <br /> i <br /> FILTER BED n Distance to nearest: Wall 2ca -t' Foundation1m' Property Line <br /> SEEPAGE PITS 11 Depth, ILK --—Sire _7Number <br /> SUMPS LI Distance to nearest: Well �ZBD f` Foundation Property Line 12;lt 69' <br /> DISPOSAL PONDS 0 <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, an <br /> 00 <br /> rules and regulations of the San Joaquin County <br /> dome owner or licensed agent's signature certifies the following; "I certify that in the performance of the work for whiZh this permit is issued, I shall no <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 cenify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all <br /> ®required inspections. Complete drawing on reverse side. <br /> Signed XTitle: Date: <br /> DEPARTMENT USE ONLY ` <br /> Application Accepted by r Date Area <br /> Pit or Grout Inspection by .'Date Final Inspection by Date <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 BOX 2009, STOCKTON, CA 95261 <br /> CK <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO y�■/�� Q 1 ��7--�ry'�, <br /> . EH 13-24(REV.1 n 51 <br /> EH 1/-2a <br />