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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I: <br /> ENVIRONMENTAL HEALTH DIVISION ) <br /> 445 N SAN JOAQUIN, PHONE (209)488-3420 � <br /> P O BOX 2009, STOCIKTON, CA 95201 <br /> PERM T EXPIRES Y FE M D T S <br /> (Complete in Triplicate) <br /> Application is hereby <br /> made to $an.Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is �11cSan <br /> nNealthit3erviceah San Joaquin County ordinance No. 51+9 and 1$62 and the Rules and Regulations of <br /> Cap <br /> Joaquin Couut�r C Lot Size/Acreage <br /> !�7 City <br /> Job Address <br /> Phone <br /> Address + <br /> pwnor'a Namo �, <br /> -o ense Phone <br /> k Addres� <br /> f Contras �. WELL'REPLACEMENT ❑ DESTRUCTION ❑ t of Service Nell ❑ <br /> I NEW WELL L7' OTHER ❑ Monitoring Well ❑ <br /> TYPE OF WELL/PUMP: ✓ _ SYSTEM REPAIR <br /> PUMP INSTALLATION C� DISPOSAL FED. PROP. LINE <br /> SEWER LINES ���� PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK -��— AGRICULTURE WELL �_ OTHER WELL�.�--- <br /> FOUNDATION w. <br /> ITYPE OF WELL PROBLEM AREA�_CONSTRUCTiON SPECIFICATIONS Dia. of Well Casing I <br /> INTENDED USE _:p;a o1 Well Excavation = ' <br /> C1 Industr� ❑ Open Bottom ❑ Manteca Specifications <br /> k L7 Tracy Type of Casing <br /> I Grout- <br /> Private ❑ Gravel Pack Depth of Grout Seal Type o1 <br /> j !"1 Other n Delta <br /> f I'f Public Aox.1 Depth ! urface Seal Installed by 4 <br /> pprI I Eastern <br /> I I irrigation � State Work Done �. <br /> i~?' type of Pump H.P. fir' <br /> Repair Work Done � Sealing Material. i Depth <br /> Well Destruction ❑ Well Diamettir — Piller Material i Depth { <br /> Depth F <br /> available within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INST!ELATION I I REPAIR/ADDITION l I-.DESTRUCTION l I tNo septic system permitted if public sewer is <br /> Installation will serve: Residents Commercial 'Other ' ` ' <br /> Number of bedrooms �- - ----• `"" <br /> Number of living units: Water table depth <br /> Character of sok to a depth of'31 11Capacity---- No.f Comp m <br /> 0 Type/Mfg SEPTIC TANK- � Method a � <br /> PKG. TREATMENT PLT.❑ Property Line ">>. <br /> Distance to nearest: Well Foundation993 <br /> SAN <br /> _ Total lengthlsi2 IC HEALT SERVICIrS <br /> LEACHING LINE ❑ No. 6 Length of lines Foundation _ — Prod .�,�..�. <br /> FILTER BED ❑ Distance 110,nal Wall DIY IAL HEAL7 <br /> i <br /> lI Depth 94- <br /> Silo Number <br /> SEEPAGE PITS Foundation Property Line � <br /> SUMPS LI Distance to nearest Wall <br /> y� <br /> DISPOSAL PONDS ❑ nc <br /> -�.- --I hereby certify that i have prepared this application and that She work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> rules and regulations of the San Joaquin County he g work for <br /> { Home owner or llice ns��9�^ as torbecome wbMctltowwarkman trtwmpensat on laws of CslifoQnia�@ Contractowhich <br /> srhiring or sub-cont acrmit is ti g gnal <br /> empty any Dar <br /> certifies the following: "i certify that in the performance sl <br /> of the work for which this permit is issued,!shall employ persons subject to workman's compen <br /> tion laws of California." <br /> The applicant m ! qutred i icas,�ernplate drawing o verse side. CeF"� <br /> Title; dg> Date: L �J <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date Area L� <br /> Application Accepted by <br /> Pit or Grout Inspection by Date <br /> Final.lnapection by Date � <br /> Additional Commence: t <br /> Applicant ^ Return all copies to: Soviroan <br /> o ant 1oHealtbublic Permit/$ervicesvices <br /> t 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> C RECEIVED by DATE PERMII'NO. <br /> � FEE AMOUNT DUE AMOUNT REMITTED p C� <br /> INFO r <br /> . EN 13-24InEV.IIwsi P �7 � CTZ! <br /> EM stile <br />