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b APPLICATION POR PERMIT � <br /> SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES # <br /> ENVIRONMENTAL DIVISI,PINF;',yu;,:;^I'�, <br /> tP O BOX 2009, STOCKTON, CA="95241 <br /> � .,;� (209) 468-3447 <br /> i 7u,One <br /> iwo` <br /> R <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application is hereby wade �an�:xithuSancounty <br /> Joaquin�Counr a ty Ordinancermit to nharuct 5l9aendol66install <br /> and the eRules and eRegulations dOf San <br /> s <br /> I. application is Stade in cow <br /> Joaquin County Public He'altb"'Servi ces. <br /> I i City' d Lot Size/Acreage <br /> Job Address <br /> Address Phone <br /> Owner's Name <br /> f 0 <br /> 00, <br /> License No. <br /> Contractor' Adress <br /> #D rd _�� W(� ' Phony! <br /> d <br /> I -' • WELL REPLACEMENT E_] DESTRUCT,.ION ❑'t�,tt of service well ❑ <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION '�. <br /> ''-1- , SYSTEM REPAIR ❑ � I <br /> % SEWER LINES DISPOSAL FLD, I PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK -- PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> TYPE OF WELL PROBLEM.AREA CONSTRUCTION SPECIFICATIONS I ± I <br /> INTENDED USE i Dia. of Well,Casing <br /> ❑ Open Bottom ❑ Manteca Die. of Well Excavation ; <br /> L� industrial 3 I Specifications <br /> Type of Casing t <br /> U DamoaticlPrivate C1 Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> Public Ia Other © Delia F ; <br /> C Irrigation Approx, Depth Eastern Suria5e edl Installed by I <br /> H.P. State Work Don <br /> Repair Work Done Type of Pump riesling Material i Depth <br /> Weil Destruction O Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: iJEW'INSTALLATION LI REPAIRIADDITION L1 DESTRUCTION G arvailablelwithin 200 feetc 5Y519m .) sewer is <br /> t .f <br /> installation will serve: Residence `Commercial Other___ ___ <br /> Number of,living units: Number.of bedrooms �- j. t"a n <br /> g , w `' ` "' - °*�Water•table depth <br /> Character of soil to a depth-of-3-feet: - ,_ 4...n..- 4- -- <br /> -,,_- �.�--. . -t _ "'Capacity_ �----- No. Compartments <br /> SEPTIC TANK. 0 Type/Mfg �� Method of'Disposa <br /> PKG. TREATMENT PLT. Cl <br /> Distance to nearest: Well Foundation — Property Lina <br /> • - <br /> LEACHING LINE Cl No. & length of lines L4 1 Property L Line - <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> i <br /> _� N I <br /> a "' SEEPAGE PITS I I Depth I Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line L---�—_—; <br /> DISPOSAL PONDS ❑ T t <br /> I hereby certify,ahat I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules end regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fol4owing: "1 comity that in the performance of the work Tor which this permit is issued, I shall not <br /> employ any person in such manner as'to become subject to workman's compensation taws of California." Contractor's hiring or sub convecting signature <br /> certifies the following: "I certify that ir�lhe performance of the work for which this permit is issued, I shall employ persons aubiec[to workman's com sa• <br /> tion Jaws of California." <br /> Thea pP li mu t call for all requir spa, ns, plate drawing o arse side. <br /> d <br /> I Title: Date:; <br /> Signed <br /> FOR AR,IEBl USE ONLY r ` 4 <br /> Date ' Area' _ Z <br /> Application Accepted by <br /> tDate Final Inspection by I Data y _= <br /> Pit or Grout Inspection by <br /> f 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 0 BOR 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT REMITTED - CK RECEIVED BY DATE PERMIT N0. <br /> INFO AMOUNT DUE CASH <br /> . . (- <br /> EH 5344 lill n 91 <br /> fY1 <br /> SEH A 26 <br />