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f APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445' N SAN JOAQUIN, PHONE (209)468-3420 <br /> p 0 BOX 2009, STOCKTON, CA 95201 <br /> PERF T EXPIRES 1 Y FR 1� D S <br /> (Complete in Triplicate) <br /> rvork <br /> Application is hereby msde.tO S'Joaquin Countyin°C unty OrdinancenNo. 549rmit to costructaando1862aand theemules andeRegulationedof Flans <br /> application is made in comp <br /> liance vith San Joaquin County Public Health Services. <br /> Job Address <br /> City Mat�K 2a)— Lot Size/Acreage <br /> -Z <br /> Address <br /> C t Phone <br /> Owner's Name C/A �5-'AS� <br /> , d n.,.n „ >LttE� 916) <br /> License No.�--phvn <br /> Contractor t t-u t^� Addresser, <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: OTHER � Monitoring Well p <br /> LL <br /> PUMP INSTAATION ❑ SYSTEM REPAIR ❑ / <br /> DISPOSAL FLD..�� PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK r <br /> SEWER LINES /�� pITSlSUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca Die. 01 Well Excavation Dia. of Well Casing <br /> nndustrial Type of Casing Specifications <br /> NY-D'omestic/Private ❑ Gravel Pack L) Tracy Type of Grout <br /> CI Other +# fl Delta Depth of Grout Seal <br /> ['1 Public ` <br /> ace Seal Installed <br /> I I irrigation �.Approx. Depth I Eastern Surf <br /> of Pump H•P State Work Done <br /> Repair Work Oahe U Type Sealing Material Iti Dept C�71J _ <br /> Well Dasttuction ❑ Well Qiameter ( --- hiller Material i Depth <br /> k <br /> Depth <br /> r <br /> PE OF SEPTIC WONEW INSTALLATION I 1 REPAIflJADDITION i I DESTRUCTION I I availabPa�wthin m <br /> TYRK: JNo SVsIff <br /> parmit'ed if public sewer is <br /> t <br /> � <br /> Installation will serve: Residence y Commercial_ Other <br /> Number of living units: Numtier of bedrooms Water tablePAWENT <br /> r Character of soil to.*depth of 3 feet:' <br /> C Capacity� No. Compa� l�.lY . <br /> SEPTIC TANK ❑ Type/Mfg Method of <br /> PKG. TREATMENT PLT.L1 �t�ol <br /> Property Lins <br /> Well Foundation <br /> Total lent PUBLIC HEALTH-SERV ii','=S <br /> LEACHING LINE ❑ No.-A Length of lines �Jy k NMENTAL HEALTH DIYi�;�}�s <br /> ' Foundation Property <br /> FILTER BED ❑ Distance to nearest: Wall �--- <br /> I <br /> Si Number <br /> i <br /> SEEPAGE PITS 11 Depth Property Line <br /> — <br /> SUMPS LI Distance to WellFoundation - <br /> DISPOSAL PONDS ❑ <br /> I hereby certity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iaws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued, 1 shall not <br /> ring or sub <br /> employ any person in such man that n thetle pa manceracting signature <br /> become caf the work foswh ch this tper i issuedion laws of , <br /> shall employ apersons}subj ct to work-contman's ompensa- <br /> cenifiss the following:" certify <br /> tion laws of California." A <br /> The applicant must all lar uir inspections. Complet! drawing on (averse side. <br /> y�ijr�c�csr Date: �.. <br /> ,Signed <br /> TMENT USE, ONLY 3� <br /> Date Z Ar <br /> Application Accepted by <br /> i Pit or Grout Inspection by <br /> Dat Final Inspection by Date <br /> Additional COMM411 te: .S� <br /> i 00 <br /> Applicant - Return all copies to: San Joaquin County Public Health Services f► � <br /> I Environmental Health Permit/Services <br /> tj 445 N San Joaquin, P O Box-2009, Stkn, CA. 95201 <br /> ` CK RECEiVEO BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO ,ry 3 0 <br /> + EH 11741REV.1IKbl 40� � 3 `�3 {fG t/ <br /> EH 14.76 <br />