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y APPLICATION FOR PERMIT <br /> 0) F�J <br /> �' ,� ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ?�vu p O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> t R <br /> z (Complete in Triplicate) <br /> Thi <br /> • <br /> Application <br /> lication is madebin ccupliance.I:!Vmade,to San lthuSan JJoatquinfor <br /> County Ordinanceconstruct <br /> No. 549and/or <br /> 1862install <br /> and thethe <br /> Rules and Regulationsof described. <br /> San <br /> F <br /> Joaquin County Public Health Services. f <br /> City 1 -aA— Lot Size/Acreage <br /> I <br /> fit` <br /> .lob Address e,_J11'Y11 <br /> Address Phone o� <br /> Owner's N _. <br /> I moi/ icense N Phon <br /> Contract Addres <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF L/PUMP: OTHER ❑ Monitoring Weil 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ] <br /> _ SEWER LINES __ --- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS, <br /> I. FOUNDATION . — AGRICULTURE WELL OTHER WELL ` <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �� — Dia. of Well Excavation Dia. of Well Casing r <br /> n Industrial ❑ Open Bottom ❑ Manteca _"Specifications <br /> Casing <br /> CJ Domestic/Private ❑ Gravel Pack n Type of Tracy Type of Groui <br /> Q Public I'1 Other I ❑ Delta Depth of Grout Seat <br /> Appror; Depth 0 Eastern Surface Seul Installed by � <br /> n Irrigation k& n State Work Done <br /> - y H.P.' <br /> Repair Work Done 0 Type of Pump t3er�ling Material i'"Depth <br /> Well Destruction O Well Diameter <br /> Depth Filler Material 4 Depths <br /> DTSTRUC-ION G (No septic system permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REQ/ADDITION -A availabis within 200 est.) <br /> Installation will serve: Residenc�u;,;ber <br /> --Commerciai-�Other t <br /> Number of living units: Iof oom .Y Wit of table depth <br /> ` + <br /> Character of toil to a depth of 3 feet: 4� <br /> Capacit <br /> SEPTIC TANK Tylpe/Mfg y. `� -- No. Compartments <br /> t <br /> A <br /> Method of DispFsal <br /> PKG. TREATMENT PLT. El4 k: r rl <br /> ! Dista to nearer.. Well Foundation..f n+ Property Line C <br /> k. 0 0_6RSA � <br /> LEACHING LINE tQST�L`I No. 8 Length of lines <br /> Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS iW STI I Depth f Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 4 <br /> 4 I hereby certify that I have prepared this application and that the work will be done-min accordance with San Joaquin.county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> Home 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 mahner as,to' become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature <br /> rc- <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 compansa- <br /> tion laws of California." '� <br /> The applicant mu t call f at kµequir d inspectjons. mplete drawing on reverse rid �� f <br /> -lj <br /> t Signed <br /> Title: Date: � <br /> FOR DEPARTMENT USE ONLY <br /> I t Date�+ EE���Application Accepted by Pit or Grout Inspection by <br /> Date Final Inspection by - Date <br /> f � — <br /> Additional Comments. <br /> Applicant ^ Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> S <br /> l FEE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> + INFO AMOUNT DU9 N Q <br /> y ♦ Lf <br /> EH13•2AtREY.tin51 J + e <br /> EN 74.211 <br />