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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 <br /> Y R <br /> T (Complete in Triplicate) 213 _055-- OP <br /> work <br /> in <br /> application is made inme4e.to SannCe Joaquinwith county for <br /> quin county ape rmit Ordinoncen/struct No. 549eando1862 and. theinstalleRules andeRegulationsdof Sane <br /> Joaquin Couay�>�blic Health 3e>;v{ces,,,, f�a/�trhp14�f 1/p/QA <br /> Iroc Lt�eSk' �C Lot Size/Acreage t�0 ocP <br /> Job Address "ll�ur IXC C O f �t 3 ga© Ile-11r, f e <br /> F ►rr�e CA 4'S/1 Phone <br /> Owner's Name9'X36` SGS <br /> t r ��{} Address <br /> C IS3s lndvs���'4� Ave'/¢�P � <br /> CH�nI rv�ce {or ff8y Phone o-(0- <br /> Fr��n��i`art G ['r��Address �n SSP C QS/ioZ License Na. _ <br /> Gor+lractor � of' S.t ice— <br /> TYPf OF WELL/PUMP: NfW WELL Well I-I <br /> WELL REPLACEMENT �] Di:STRUCTION ❑ �t Monitoring cell <br /> + PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER <br /> SEWER LINES �---- DISPOSAL FLD. ?ROP. LINE <br /> UM <br /> DISTANCE TO NEAREST: SEPTIC TANK pITSlSUMPS <br /> C$PF FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELT. PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> y „ <br /> Dia. of Well Excavation 'C Dia. of Well Casing <br /> fl Industries ©��11Open Bottom LJ Manteca <br /> IrYCiravel Pack }Tracy Type of Casing sch t1(7 1/G Specifications r <br /> L) Domestic/Private � /,n�� %Qj"(? Type of Grout <br /> I'll Other ❑ Delta Depth of Grout Seal ��+ r .,�..,�J.r�. <br /> r M public <br /> 1Q,.Aoprox. Depth 0 Eastern Surface Seal Installed by_ - e <br /> ClG Irrigation ��/� State Work Done _ <br /> Repair Work Done L3 Type of Pump �— H.P. <br /> 1f Sealing Material i Depth <br /> Well Destruction O Well Diameter _ --- Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR1ADDITION 0 DESTRUCTION G (No septiclable syst m0 i' ifed if pubiic sewer isavaY� <br /> ' N 1 <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms Water table depth dr <br /> Character of soil to a depth of 3 feet: . No. Compartments 4 <br /> SEPTIC TANK 0 Type/Mfg Capacity <br /> L-1Method of Disposal <br /> PKG. TREATMENT PLT. <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> I <br /> Total length/size <br /> LEACHING LINE C1No. B Length of Eines <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> j DISPOSAL PONDS ❑ <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, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature Certifies the following, 'I comity 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 shall employ persona subject to workman's compansa. <br /> tion laws of California." <br /> The applicant m I call for all req d i tions, Complete drawing orytirev�r sides c!75 <br /> Signed Title: KK 1 /GL Date: �D — <br /> FO DEPARTMENT USE ONLY / <br /> Application Accepted by <br /> .. Date Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Data <br /> Additional Comments: <br /> Applicant - Return all copies tot ENVIRONMENTALCOUNTY JOAQUIN PUBLIC HEALTH <br /> HEALTHDIVISIONPERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDRECEIVED BY DATE PERMIT'NO, <br /> INFO CASH <br /> ♦ EH 13241REv.I?H51 Jp ,. ! O O— <br /> EN,bye <br />