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Z7 Q� APPLICATION FOR PERMIT / l <br /> <SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r q { <br /> ENVIRONMENTAL HEALTH DIVISION <br /> E 445 N SAN JOAQUIN, PHONE (209)468-3420 <br />+ J P 0 BOX 2009, - STOCSTON, CA 95201 <br /> F <br /> r 1 <br /> _29—MIT EXPIRES I YEAR FROM D TE QQTjV1 <br />' ' (Complete in Triplicate) <br /> Application is hereby mads to San'Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> I Joaquin County Public Health Services. <br /> Job Address Cit Lot Size/Acreage Q <br /> Owner's Name Q R ) 1n Address Phone <br /> Contractor �lz� f i( f� Address '-Z>) et Lir cense No. Phone <br /> TYPE Of WELL/PUMP: NEW WELL TR WELL REPLAC ENT 1.1 DESTRUCTION 0 out of Service Well p <br /> Pi1MP_INSTA•LLATION ❑ SYSTE <br /> DISTANCE TO'NEAREST: SEPTIC TAN , .__ _REPAIRH0 _ OTHER 0 Monitoring Well <br /> Q <br /> K EWER LINES DISPOSAL FLD. PROP. LINE - <br /> FOUNDATION RICULTURE ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A EA ONSTRUCTION SPECIFICATIONS i <br /> C7 industrial 0 Open Bottom 0 Manteca.r Dia. of Well Excavation Dia. of Well Casing <br /> (I Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing-_ , <br /> 1'1 Public - Specifications <br /> t 1"1 Other ' fl Delta h th of Grout Seal Type of Grout <br /> I 1 Irrigation I —Approx. Depth I I Eastern Su` • Saul Installed by <br /> Repair Work Done ❑ Type of Pump H.P, <br /> State Work Done_ f <br /> Well Destruction 11 ' Well Diameter I Sealing Nateri i Depth <br /> Depth Filler Material i Depth <br /> YPE OF SEPTIC WORK: NEW INSTALDMON 1 I REPAIR/ADDITION DESTRUCTION I I filo septic system permitted if public sower is <br /> �` available within 200 test.) j <br /> Installation will terve: Residence -Commercial%& Other�� <br /> Number of living units: Number of bedrooms ' <br /> Character of sok to a deptfj-of-1,feel •" .; , <br /> Water table depth f <br /> SEPTIC TANK: p.Type/Mfg 4 Capacity's - - fJo. C6mpartments." <br /> PKG. TREATMENT PLT.0 •-.'� <br /> Method fo Disposal <br /> Distance to nearest: Well Foundation <br /> • r �n Property Lula w <br /> LEACHING LINE No. 6 Length of lines l <br /> Total length/size <br /> FILTER BED L1 Djstarca to rwreet:.a Well -�Q Foundation /� A� <br /> 1 Property Line <br /> SEEPAGE PITS Depth -Z1 Size t <br /> Number .� ave <br /> SUMPS LI Distance to nearest: +n+ell . L Foundation `.Property Line <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, an <br /> rules'and regulations of the Sen Joaquin county I <br /> Home owner or licensed agent's <br /> signature certifies the lollowin + <br /> g: 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,lam of California."'Contrector s hiring or sub-contracting signature k <br /> certifies the following: "I Certify that in the performance of the work for which this <br /> tion*we of California." permit is issued, l_811611 employ perions subject to workman's compenss- <br /> The applicant must a for r uir inspections. Complete dravOngon reverse si e. <br /> Sig <br /> Title: <br /> -� Date: F <br /> y OR DEPARTMENT USE ONLY - l <br /> Application Accepted by Laik. <br /> 1 <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date `� 7 <br /> Additional Comments: <br /> Applicant—Return "all copies to -San Joaquin Count - F <br /> Y PublicHealthr3er lees. ;Q. <br /> Environmental Health permit/Services )' <br /> 445 N San .loaquin, P O Box 2009, Stkn, GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO / CA RECEIVED BY DATE PERMIT'NO. <br />. EH 17.29 IREv. er y �o <br /> EN 14•I9 t� P <br />