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APPLICATION FOR PERMIT <br /> A UIN COUNTY PUBLIC HEALTH SERVICES <br /> SAN J@ <br /> O <br /> W ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> G , P O BOX 2009, STOCKTON, CA 95201 <br /> P ET EXPIRES 1 YE FROM D TE ED <br /> ' t# (Complete in Triplicate) j <br /> in described. <br /> Application is hereby made to Xaa with San <br /> County far a permit rdinancenNo. 549struct aand o1862sand the tall eRules and vork eRegulations of Sane <br /> application is made in ccmpliance with Ban Joaquin county <br /> Joaquin County Public Health Service r <br /> r City t size/Acreage <br /> lie11 <br /> Job Address ". <br /> i i Address ` ~~tel Phone <br /> OwS„er'ss Name <br /> Y I Phone <br /> Contractor <br /> dress • S <br /> License No. <br /> WMP: r NEW WELL 13 WELL REPLACEMENT JCI DESTRUCTION ❑ put of Service Weil <br /> TYPE Of ELL/PU <br /> C3SYST M REPAI <br /> 11 f: OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ C1' ;A <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO.NEAREST! SEPTIC TANK SEWER LINES PITS/SUMPS <br /> T,FOUNDATION AGRICULTURE L ; OTHERfWELL <br /> — <br /> SE ` S OF WELL PROBLEM AREA 0 TRUCTI <br /> INTENDED UTYPE ON SP <br /> ECIFICATIONS , <br /> _ pia. of Well Casing ' <br /> n industrial fa tope n Bottom ❑Manteca Dia o1 Well Excavation ` Specifications <br /> Ty of Casing_ , <br /> Cl Domestic/Private GI Gravel Pack L7 Tracy D pth o1 Grout Seal Al `Type of Grout <br /> I'1 Public I.1 Other k fl Del 4 <br /> I I Inipation ___.Approx. Depth I I stern Surface Seal Installed by R <br /> State Work Done <br /> Repair Work Done U TypVbf Pu FP . Seeing Material 4 Depth <br /> _ WeH Destruction © Wel! Diameter „_ filler Material i Depths j <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRlADDITIONFII DESTRUCTION I I afvailablerwthin 200 feetstem permitted it public sower is <br /> Installation Willserve: Residenceixmmercial Other ILO <br /> �,..'. <br /> Number of living anus: Number of bedrooms . �. Water table depth <br /> Character Of sola to a,depth of 3 feet: .N Al ~� <br /> 110, �� Capacity No. Compartrr»nts . <br /> j SEPTIC TANK D "Type/Mfg Method of Disposal <br /> PKG.1REATMENT PLT. Cl r �" <br /> Distance-'to nearest: \Well,./ a Foundation Property dine - <br /> + <br /> .LEACHING LINE f ..'�No. & Length of lines ' To I Iength/aixe <br /> FILTER BED CI Distance to nearest: Well *oundation` Property Line <br /> "Nu bar <br /> SEEPAGE PITS a Depth Sire �( <br /> SUMPS LI Distance to near t: Well Foundation Property Line T <br /> DISPOSAL PONDS ❑ t <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 /> rubregulations Of and regulatioOf..lh*San Joaquin County " i- � y <br /> ! Hoe owner or licsnssd agent's signature certifies the following: l certify that in the performance of the workk for which this permit issued, I shall not <br /> Horne <br /> ampioy.any:parson 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 artily that In the performance of the work forwhich this permit is issued, I shall employ persons subject to workmen's compenss- <br /> tipn Laws of California." -� � {+``, <br /> The applicant ust call for wired in coons. Complete drawing on reverse side. <br /> Signed Title: <br /> 1 Date: ,--I <br /> ` FOR DEPARTMENT USE ONLY <br /> ' Dates Area <br /> Applicatbri Accepted by t i. <br /> cy��4 Data <br /> Ph r Grout Inspection by ! Date r l — Final Inspection by <br /> i <br /> Additional m <br /> ional Coments. - <br /> • Xqt <br /> Applicant - Return all copies San Joaquin County,Public Health Services <br /> Environmental Health Permit/Services <br /> i 445 N San Joaquin, P O Box 8009, Stkn, CA 95201 <br /> FEEK RECEIVED BY DATE PERMIT'NO. <br /> INFOEAMOU�NTDIUJE AMOUNT REMITTED CASHEH,�2.IRiti.+,K s+ , 0 0 1 H� 6 y 6 3 <br /> EH 11.75 <br />