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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 /> PERMIT E%PIRES I Y FROM DATE S <br /> (Complete in Triplicate) <br /> Application in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in c0111ii1lance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Job Address A4pa.p4m, Al Cit o ize/Acreage <br /> i <br /> Owner' ame GO e Phone <br /> Contractor ddress �No_ <br /> bLicens hone FbarTYPE OF WELL/PUMP: q -NE WELL ❑ WELL REPLACEMENT CTION Out of Service Well Gl <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ I'lonitoring'Well ❑ <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> •- FOUNDATION AGRICULTURE WELL OTHER WELL 3� r PITS/SUMPS <br /> NTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECfFIC NS, <br /> I`nt�strial 0-Open Bottom f_7 Manteca Dia. of Well Excava ' {Dia, of Well Casin <br /> l+r�omestic/liwta: G'Giavel Pack ❑ Tracy Type of Casing_ Specifications <br /> 1.1 Public 1-1 Other n Delta Depth of Grout Seal _ 11__ _ T <br /> ype f Grout <br /> t I Irrigation w. ai <br /> Approx. Depth I I stern urface Seal Installed by <br /> Repair Work Done T pa of Pump H.P. State Work Done <br /> Well Destruction Wolf Diameter Sealing Naterial A Depth <br /> Depth F111er Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I. D ST u N fsV*11 enml <br /> tted if public newer is <br /> Installation will serve: Residence` CommercialOther <br /> � <br /> Number of living units: Number of rooms <br /> Character of soli to■depth of 3 feat. -a have ex imrjWit hn <br /> SEPTIC TANK- _ ❑ Type/Mfg � Q'�oin��fT,f171sDts <br /> MW th <br /> PKG. TREATMENT PLT. Q t <br /> n�nydronrne tal Heaiffft � tloaal <br /> Distance to nearest: Well ops ty Line -- <br /> e 1 i � t <br /> LEACHING LINE ❑ . No. b.Length of lines Total length/size <br /> FILTER BED. 0 Distance to nearest: Wei oundation Property Line <br /> SEEPAGE PlfS�i 11 Depth Siie - Number <br /> SUMPS LI Distance to nares• Well Foundati Property Line <br /> DISPOSAL PONDS-' - 0* <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin county ordinances, state Ifiws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or ' gent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I hell not <br /> employ any son in suc manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> Certifies following: "I c nify that in the performs o the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion le of CalI ornis." <br /> Thea icant mus f ah ere drawing on v/y ide. <br /> Signed <br /> Date: <br /> FO MENT USE ONLY <br /> Application Accepted by Date (0-���_ Area oil 15 SL <br /> I' <br /> Pit or Grout Inspection by J /J Date f� Final Inspection by pate <br /> Additional Comments: <br /> Applicant - Return all copies to:, Ban,Joaquin-County-Putil3aHealth Services ` <br /> -+ Environmental Health Permit/Services - <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DdE AMOUNT REMITTED CACK RECEIVED BY DATE PERMIT'N0. <br /> INFO SH <br /> • EH t 3-24 IItEV.I/R 61lA! [7 33 <br /> y7 rfF d/� 3 F3 -/000� <br /> EM 1 .76 l r� c (;�vc© <br />