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APPLICATION FOR PERMIT E- <br /> SANIJOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENvIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> 201 ' <br /> P O BOX 2009, STOCKTON, CA 9 �p �I CK <br /> I <br /> PER![ T EXPIRES I YEARFR N D TE MOM <br /> (Complete in Triplicate) <br /> work herin described. <br /> Application ihereby <br /> viade.toto� JoewithuSaaCJosquinoCounty ordinancenNo. 549aando1862aand thee <br /> eRules andeRegulations Sans <br /> application is ein <br /> Joaquin County Public Health Services. <br /> Lot Size/Acreage <br /> --'J,b Address t <br /> 1r` Phone /'�[ �q <br /> r Address I'V )%T� - D 6 It <br /> ,/lSwner's Name 111 <br /> '� License No. �phone <br /> Contratta i Address <br /> NEW WELL ❑ WELL flEPLACEMENT ❑ DESTRUCTION I1 Out of Service we <br /> ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring 4fe31 ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR ❑ <br /> R LINES DISPOSAL FLO. PROP. LINE <br /> DISTANCE TO NEAREST- SEPTIC TANK_ SEWER �------- DTHER WELL PITS/SUMPS _ <br /> FOUNDATION.. AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom [3 Manteca Dia. of Well Excavation <br /> L1 Industrial r Type of Casing_ Specifications <br /> ck� n t <br /> C.1 Domestic/Private ❑ Gravel Pa ❑ Tracy Tyle of Grout \��}► <br /> I'i Public <br /> 1-1 Other. n Delta Depth of Grout Seal ; <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> State Work Dona, <br /> Repair Work Done U Type of Pump �--- H.P. <br /> Sealing Materlal k Depth <br /> Well Destruction ❑ Well Diameter Filler Material A Depth <br /> Depth <br /> TYPE OF SEPTIC WDRK: NEW INSTALLATION I 1 REPAIflIADDITIDN I I DESTRUCTION lNai1 ble'within 200 feet.) or public saws 1 <br /> I <br /> Installation rve: Residence Commercial— Other�r <br /> Ik Number of living units: Number of bedrooms 'r ter table depth <br /> Character of wit to a depth of 3 feet:I I. Capacity No <br /> Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal \ <br /> PKG. TREATMENT PLT.❑ Property Line <br /> Distance to nearest: Well. F ation v <br /> Total length <br /> LEACHING LINE Cl No. 6 Length of lines --Foundation. -Property.Line <br /> FILTER BED 0 Distance to Well <br /> l pth 1 Size Number <br /> SEEPAGE PITS Property Line �- <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOS NDS ❑ J-- tt <br /> I retry 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 /> 1 rules and regulations of the San Joaquin County !. r ` <br /> Home owner or liunsad agent's signature certifies the following: "I cartity that in the performance of the work for which this permit is issued, I shall not <br /> employ any portion in such manner as to became subject to workman's compensation laws of California."Contractor's hiring or sul�contractinq signature <br /> certifies the following: '•I certify that in the performance of the work for which this permit is issued, 1 shall employ persona subject to workman's compensa <br /> tion laws of California." <br /> # ad inspections. Complete drawing on reverse side. <br /> The applicant must call for ail equir <br /> Title: CS f. Date: <br /> Signed <br /> t } R PARTMENT USE ONLY <br /> Area <br /> .ate � <br /> Application Accepted by <br /> Final Inspection by . pats <br /> IFPit or Grout Inspection by Date�- <br /> s c �� �!� !� lel > s <br /> Additional Comments: `i flf cry ��r <br /> i <br /> i San Joaquin County Public Health Service <br /> Applicant - Return all copies to: <br /> Environmental Health Permit/Services <br /> I 445 N San Joaquin, P O ox 2009, Stkn, CA 95201 <br /> fw <br /> wPERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED ESH <br /> REEIVED BY D TE ` <br /> a INFO <br /> 'EM 13.24 Mgv.t/w 5l <br /> EM 14-26 <br />