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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN COUNTY L�LTIVVICES <br /> ENVIRONMEN g DIVISION <br /> # <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> p T E%PIRES YAR FR !_1 M&T_E_J§_SkW <br /> (Complete in Triplicate) <br /> y� permit to construct and/or lnatall the work herein described. This <br /> Application is hereby made to San 'Joaquin County for s <br /> e with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of n <br /> application is made is complianc <br /> Public Health Services. r <br /> Joaquin County U_ -t Lot Size/Acreage <br /> Job Address Com/ � <br /> rc <br /> Phone <br /> Address <br /> Owner's Name �* <br /> &/I Old License No. Ph°ne <br /> Contractor, - - =- _Address <br /> NEW WELL ❑ WELt REPLACEMENT ❑ DESTRUCTION 0 Out of service well ❑ <br /> TYPE OF WELL! UM OTHER Monitoring well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> SEWER LINES DISPOSAL FLD.— ,PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK— - AGRICULTURE WELL OTHER WELL PITSlSUMPS <br /> FOUNDATION d <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Industrial i Specifications <br /> Type of Casing_ <br /> Domestic/private ❑ Gravel Pac ❑ Tracy Depth of Grout Seat Type of Grout <br /> VI Public (:1 Other fl Delta <br /> I I Irrigation <br /> Approx. Depth t I Eastern urface Seal installed by <br /> U r��- H P $ut4 Work Doe <br /> Repair Work Done j7 Type of Pump" Selling Material Ik Depth <br /> Well Destruction ❑ Well Diameter i <br /> Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION".) I RiEPA1Rl,11=1 ON:i I .DESTRUCTION l I available within 200 feat led i! public sewer is <br /> Installation will serve: Residence Commercial_ Other— ( t } <br /> j Number of living units: Number of bedrooms Water table depth <br /> Character of soA to a depth o1 3 feat: �• No. Compartments <br /> SEPTIC TANK 0 Typal Mfg Capacity��--- <br /> '''� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ property Line <br /> Distance to nearest: Well Foundation <br /> Pr%I Iwo DO <br /> Total-length/size <br /> I LEACHING LINE Cl No. b Length of lines Property L <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pe y r <br /> �' Sita Number - <br /> SEEPAGE PITS i I Depth �y, VISES <br /> Foundation Prot-uoLiv <br /> 4 <br /> SUMPS, Cl. Distance to nearest: Well "_ _ L HEALTH DIVISJL)N <br /> i DISPOSAL PONDS ❑ "— <br /> Ihereby certify that 1 have prepared this application and that be done in accordance with ban Joaquin county ordinances, state laws, and <br /> t the work w <br /> rules and regulations of the San Joaquin County <br /> agents spnsture cenifies the following: 'I certify that in the performance of the work for which this permit is issued, I shall not <br /> ' tion laws of California.'; Contractor's hiring or sub-contracting signs <br /> empty any person in such manner as td 'lure <br /> Home owner or licensed become subject to work men's compensation <br /> candles the following:"I oenify,that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compenss• <br /> tion laws of California." 1 <br /> The applicant must call for required ionapsctions. Complete drawing on reverse side. <br /> c !]/�h.. -air Date: <br /> Signed Title: <br /> j S <br /> OR DE ME <br /> E �.3 Araa� <br /> Application Accepted by <br /> - Date <br /> IDate Final Inspection by Det <br /> i <br /> Pit or Grout Inspection by <br /> kAdditional Comments: <br /> Applicant - Return all copies to: San Joaquin County public Health services <br /> Environmental Health Perrmit//SeOrvic s CA 95201 <br /> t 445 N San Joaquin, <br /> CK REC VED BY DA PERMIT'NO. <br /> PEE MOV !1 AMOUNT REMITTED C <br /> 1 <br /> . EM t7•2I IREV.I�e e1 <br /> r <br /> EM 14.26 <br /> t <br />