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r - <br /> r <br /> w. <br /> 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 O BOX 2009, STOCKTON, CA 95201 <br /> -EMIT EXPIRES 1 YE FROM DATEISSUED <br /> (Complete in Triplicate) <br /> r <br /> Application is hereby made to Baa Joaquin County for a permit to construct and/or install the vork herein described. This <br /> dinance Ko. 549 and 1862 and the Rules and Regulations of Ban <br /> application is made in compliance with San Joaquin County Or <br /> Joaquin County Public Health Services. <br /> Job Address _ d.�f� <br /> LtD.— (� M _ City s � Lot Size/Acreage <br /> r? E 1 �CjZ7 [ �PtI�T Phone Z[J4e� <br /> Owner's Name i� ��a Address I <br /> Contractor No Ack <br /> UI'►'1Le--O­Address S License No. -�0 s/ Phone <br /> WELL REPLACEMENT n. DESTRUCTION Cl Out of Service Well Ll <br /> TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ t6onitoring Well ❑ <br /> PUMP INSTALUITION 8-" SYSTEM REPAIR ❑ <br /> ' � DISPOSAL FLD. PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION. f AGRICULTURE WELL `�- OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia of Well Casing <br /> C] Industrial ❑ Open Bottom ED Manteca Dia. of Well Excavation (� <br /> Type of"Casing_. Specifications LJ <br /> ti�Fbmestic!Privets <br /> El Gravel Peck CJ Tracy <br /> Il Public CI Other fl Deita Depth of Grout Seal Type of Grout <br /> I i Irrigation Approx. Depth I I Eastern �u ace Seat/ Installed by <br /> Repair Work Done U Type of Pump H!P• Z State Work Done { <br /> Sealing terial 4 Depth uhT t4 i <br /> Well Destruction ❑ Well Diameter - /[1Q" <br /> Depth 1 ]tiller Material_i_Depth�-- - --�- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION l I DESTRUCTION I INail septic <br /> withm permi(eat ted if public sewer is <br /> II' Installation wit serve: Residence Commercial_ Other <br />` Number of living units: _. Number of bedrooms <br /> Character of troll to a depth of 3 feat: 1 f Water table depth L.3 <br /> SEPTIC TANK. 0 Type/Mfg F Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ r� Method of Disposal }►� <br /> Distance 10 nearest: Well Foundation Property Lina <br /> " . Total length/size <br /> LEACHING LINE 0 No. A Length of lines " <br /> -- - <br /> FILTER BED ❑ Distance to,,nearest. will Foundation '� Property Line <br /> SEEPAGE PITS I I Depth {1 Size "r Number <br /> SUMPS LI Distance t10 nearest: Well Foundation Property Line - <br /> DISPOSAL PONDS ❑ E <br /> I hereby certify that I have prepared this application and that-the work will be done iri accordance with San Joaquin county ordihancas, state laws, and <br /> rules and regulations of the San Joaquin County I shall not <br /> Home owner or licensed agent's signature certifies the following: '9_certify that in the performance of the work for which this permit is issued, <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on a si -30 r3 <br /> i 1jw <br /> Signed � Title: .Date: <br /> t{+ FOR DEPARTMENT USE ONLY 1� <br /> I Application Accepted by -5 Date — y� Area <br /> t Pit or Grout Inspection Date z Final Inspection by ' �!t Date r <br /> 1 � <br /> Additional Comments: <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> b 445 N San Joaquin, P 0 Box 2009, Stkn, CA 85201 <br /> FEE AMOUNT DUES, AMOUNT REMITTED CASH I RECEIVEDBY DATE PERMII'NO. <br /> INFO <br /> . EM 0.24(REIVY V.It T t� S i � ' U / VT <br /> i+ <br /> EH 1446 r 1 <br />