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r 'f <br /> A APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONXENTALTHEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON; CA 95201 <br /> i <br /> PERMIT ESP I RES 1 XEM FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in ceatpllance with San.Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> l <br /> Job Address City kaw Lot Size/Acreage �V /-�f�►G � <br /> t <br /> F Owner's Name '' Address e <br /> R _:6 <br /> Contractor ress . Gik,e No, Z-V Phone <br /> !TYPE OF WELL/PUMP: NEW WELLS WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well C] <br /> .�,. DISTANCE TO NEAREST: SEPTIC TANK,- -SEWER-LINES___�_-�"_—��: DISPOSAL FLD" -PROP...LINE, <br /> r <br /> FOUNDATION " AGRICULTURE WELL- OTHER WELL ^`� PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' !❑ Industrial ❑ Open Bottom C] Manteca Die. of WeN Exc vation Dia. of Well Casing <br /> �,p.� <br /> !(-.1 0,omestic/Private t �Gfavel Pack Cl Tracy Type of CasinSpecifications" <br /> ;I'1 Public f'1 Oiher f"i Delta Depth`of Grout Seai Type of Grout 8�d�fa/ytiL <br /> ,�rriga(lon _A" ax. Depth IKEasiernOAW Surface Seal Installed b <br /> Repair Work Done 0 Type of.Pump H.P. State Work Done <br /> Well Destruction ❑i Well Diameter Sealing Material li Depth <br /> ' 1 Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 4 Installation will some: Residence Commercial Other ! <br /> Number of living units: Number of bedrooms_ <br /> ' Character of soil to a depth of 3 feet: a <br /> SEPTIC TANK. D Typo/Mfg ` Capacity o. ompartmen s <br /> PKG. TREATMENT PLT.❑ Metho_ AN4,5il 1993 <br /> i Distance to nearest: Well Foundation Prop y,I*' L HEALTH <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> I FILTER BED D.-Distance to nearest: Well Foundation_ Property-Lino <br /> I SEEPAGE PITS I I Depth _ Sire Number. <br /> d SUMPS. Ll Distance to nearest: Well Foundation Property Lino <br /> 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 /> eulet and regulations of the San Joaquin County <br /> Homs owner or licensed agent's signature certifies the following: "I certify 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."Contragtor'a hiring of 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 i5ersons subject to workman's compenss- <br /> tion laws of California." P. <br /> r The.appI 16 for allr ifsd inspections. Complete drawing on r as side. <br /> SignedAA Title: Date: <br /> t <br /> ;rA=RTMU5 <br /> 1 <br /> f Application Accepted by of Dass <br /> I <br /> Ph Groin nspsction by Daae Final Inspection b Dat <br /> Additional Comments: <br /> M Applicant - Return all c les to: San oaquin County ublic Health Services - <br /> F Environmental Health Permit/Services <br /> t 445 N San Joaquin, Box 2009, Stkn, CA 95201 <br /> FEE <br /> INF AMOUNT DYE AM NT REM ED K RECEIVED BY D E PERMIT NO. Ir/1 <br /> l E141324IREV.tix61 <br /> EH 14.76 �� <br />