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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> y 'J ENVIRONIMTAI;' HEALTH DIVISION <br /> 1445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOC.KTON, CA 95201 <br /> PERMIT E%PIRES''1 YEAR FROM DATE ISSUED <br /> F <br /> (Complete ,in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> with Sam Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is spade in compliance t <br /> Joaquin County Public Health Services. Q Q <br /> J �a City a ` Lot Size/Acreage a <br /> !Y Job Address � Q j <br /> YYY�„ .0 Phone <br /> .Owner's Name `� A d ss _ I <br /> }� #�. <br /> Cantracior Q AddiessJ - - License No. <br /> y� Phone ,. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ X.Material & <br /> LACEMENT DESTRUCTION ❑.out of service Well C <br /> EM REPAI ❑ OTHER ❑ Monitoring well <br /> PUMP INSTALLATION ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWERDISPOSAL FLD. ,PROP. LINE <br /> FOUNDATION AGRICL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARETR CTION SPECIFICATIONS <br /> f7 Industrial ❑ Open Bottom ❑ Manteca a xcavation — Dia. of Well Casing <br /> fa DomesticlPrivate L3 Graves Pack ❑ Tracy x. f Casin `-""`"' Specifications <br /> I'} Public Cl Other fl Delta of G''out al + I RType of Grout <br /> ii Irrigation �,Approx'`Depth I i Eastern wa Seal install by ' <br /> of Pump H.P. }•_ tateWdRepair Work Done 0 Type Well Destruction ❑ Well Diameter eaial & Depth r. <br /> Depth Filler Material & Depth ; <br /> r <br /> I i ' 'DESTRUCTION l I INo septic system permitted if public sews.is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial _ Other <br /> Number of living units: -A — Number of bedrooms r AN <br /> Character of soil to a depth of 3 feet: <br /> [ Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No.rCampartrttents <br /> PKG. TREATMENT PLT. ❑ r Method of spo al <br /> Distance to nearest: Well V�oundation�D Property,Giie f}- <br /> - r <br /> LEACHING LINE,;-_ �. No. & Length of lines _ <br /> Total length/size I <br /> i <br /> FILTER BED <br /> O Distance to nearest: Well oundation Property.-Ling ' ' <br /> ..-. <br /> Number <br /> SEEPAGE PITS I i Depth, Size <br /> SUMPS Cl Distance to nearest: Well _ Foundation _ Property Line1� <br /> POSAL PONDS Cl <br /> I I hereby,cenify that I have�prapared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> 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 /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I*hall employ pereons subject to workman's compensa- <br /> tion laws of California." } <br /> The applicantust call for all required inspe. ns. Complete drawing on reverse side. <br /> Signed X Title: _� i >� Date: <br /> FOR DEPARTMENT USE ONLY <br /> i Application Accepted by ,r <br /> Date ^ <br /> Pit or Grout Inspection by Date Fines Inspection b.4 Date <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 95201 <br /> &�_ <br /> FEE AMOUNT DUE, AMOUNT REMIT-1 CASRECEIVED Y ATE PERMIT NO. <br /> ! INFO <br /> i /yp S <br /> iFk EM13.2a1REV.irx61 r0.0 toa 7V�` <br /> f EH t4de <br />