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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468--3447 +A <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a perad.t to construct and/or install the vork herein described. This <br /> application is tirade in.cotrrpiiance,vith San Joaquin County Ordinance No. 549 and 1862 end the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> �]--v City t size/Acreage <br /> Job Address <br /> s Phone <br /> a, ss <br /> Owner's Name �+ <br /> License -,p <br /> ���� �-© rJ ��— 1'hon �' <br /> Conti 3�C �E��_P <br /> ervlce Well C1TYPE LLlPUM : NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L�tr <br /> OTHER ❑ Monitoring Well <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELSEWER LJNESL <br /> L OTHER WELL PITS/SUMPS <br /> FOUNDATION <br />( <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> f_l In trial ❑ Open Bottom 0 Manteca Dia. of Well Excavation �; r <br /> Type of Casing Specifications <br /> omestic/Private O Gravel Pack D Tracy Type of Grout ' <br /> In Public 1:1 Other ❑ Delta Depth of Grout Seal <br /> GI Irrigation Appra Depth P Eastern L Surface Seal installed by <br /> H P State Work Dona <br /> k Repair Work Done Type of Pump Sealing Material i Depth <br /> Well Destruction- 0 Well Diameter Filler Material fe Depth 4 <br /> � a�'G � Depth . . r { <br /> TYPE Of SEPTIC WORK: NEW"INSTALLAT ON 0 REPAIWAODITION M DESTRUCTION Cl (No septic system <br /> shin 2013 test <br /> perm1tjed if public sewer is "1 <br /> ea � <br /> Installation will serve:�Rssld hce Commercial Other f y rte. <br /> Number of living unite:' Number of bedrooms t a.f;• ,. <br /> Character of wit to ■ depthof 3 feet: Water_table_depth ��� _ <br /> / Capacity No. Compartments '� <br /> SEPTIC TANK D Type/Mfg � <br /> PKG. TREATMENT PLT. 0 1 / Method of Disposal <br /> r" Distance to nearest: Well Foundation. Property Liner7m.. <br /> Total length/size <br /> ' LEACHING UNE C1 No. & Length of lines yy, t 4 r Property 0 ����" <br /> FILTER BED Cl Distance to nearest: Well . Foundation S R u <br /> SEEPAGE PITS _11-.I Depth4 Sire Numbs <br /> SUMPS LI Distance to nearest: Well Foundation Props -�1-1i ,� <br /> DISPOSAL PONDS ❑y _; 4 <br /> f 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 /> l rules 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, 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 /> comilies 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, <br /> laws of California." <br /> ! The applicant m e uire lets drawing on rj✓��rSO aalioe�. _ <br /> Date: � �! <br /> Signed Title: . <br /> FOR DEPARTMENT USE ONLY <br /> f Date 7 Q �'� Ar <br /> Application Accepted by <br /> Dats� � <br /> Pit or Grout Inspection by Date Final Inspection by _ <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 O ISO 20090 STOCKTON. CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> INFO AMOUNT DILE AMOUNT REMITTEp i <br /> ��.�j //���� Z q 4� 2 �-zcf69 <br /> . EH 17.24 IREV.r i n 51 [s.} �-.� " . <br /> EH 74.26 <br />