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APPLICATION FOR PERMIT <br /> r <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -­ <br /> ENVIRONMENTAL <br /> ERVICES ;,ENVIRONMENTAL HEALTH DIVISION T <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 �� <br /> 1,nMI T EXPIRES 1 YEAR rROM DA's ISSUSi? <br /> -- RON T <br /> (Complete in Triplicate) ����� /�����""A�. �� AIT� ; <br /> Application is hereby mads to San Joaquin County for a permit to construct and/or install the WorkTheie'i���.Ln bed. This <br /> application Is made in coatpliance-xith San Joaquin County Ordinance No. 549 and 1862 and the' Rulea and Regulations of San <br /> Joaquin County Public jHealth Services. 4L <br /> Job Address r City_�.. Lot Size/Acreage <br /> 1 ;♦ <br /> Ow is Nam tossi Phone <br /> 70, r or / d !�1CO �� �Q-�- � i <br /> License No. Phone <br /> TYPE OF WELL/PUMP. NEW WELLEl WELL REPLACEMENT/0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well {� <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> iNTEf4DEO USE '- 'TYPE pF-VELI.'-'-PRaBtiEMAOE71--'�CONSTRUCTiON SPECIFICATIONS" <br /> C.1 <br /> 1 ustrral ❑ Open Bottom © Manteca Dia, of Well Excavation Dia. of Well Casing <br /> 4omestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications 4 <br /> M Public (el.Other - Cl Delta Depth of Grout Seal Type of Grout <br /> Ml Irrigation .Approx. Depth E sternace Soul <br /> Installed by <br /> Repair Work Done 0 Type of Pump A_ H.P. _ —_ <br /> Well Destruction ❑ Well Dia of ' Sealing Material i Depth q✓ <br /> Delp <br /> th -� Filler Material A Depth' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION G INo septic system permitted it public sewer is <br /> available within 200 feet.) # <br /> Installation will serve: Res dente— Commercial_.-•_ Other <br /> Number of living units: Number of bedrooms 4 <br /> Character of soil to a depth of 3 feet: Water table depth �v <br /> SEPTIC LANK. ❑ Type/Mfg Capacity No: Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line a <br /> LEACHING LINE 0 No. 8 Length of lines Total lengthlsiie' ` <br /> FILTER BED n Distance to nearest: Well "''foundation Property Line <br /> All <br /> ' 1 <br /> SEEPAGE PITS I I Depth Number " r <br /> SUMPS L] Distance to si est:, ell' r� Foundation_ Property Line t <br /> DISPOSAL PONDS ❑ <br />_-«�- 1 hereby-conify•ihat-l-have-pr pared-this�application and that the work will Oe done in-accordance with.San Jbaquin-county•ordinances,-stale-iaws;-end---- <br /> rules and regulations of the San Joaquin County '"� i <br /> Home owner or licensed agent s signsturj certifies;the following; ',I•y#r ify 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 pecome sublect•lo workman's compensation,laws of California." Contractor's hiring or sub-contracting signature <br /> Certifies the following; "I certify that in the performance of the work:for whicFi,this permi(is issued;l shall employ persons subject to workman's compensa• ;. <br /> tion laws of Calif rnia." i v *.r <br /> The applicant t.call for!!0t1rer irispgctions� Complete drawingon reTitle ----Data: '•�-- F <br /> R DEPARTMENT USE ONLY <br /> Application Accepted byT Date Aram/ i <br /> ti <br /> .y <br /> Pit or Grout Inspection by Date Final Inspection bypate 2" Z g' 7b <br /> Additional Comments: <br /> Applicant - Return all copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2049, STOCKTON, CA 95201FEE <br /> \y <br /> INFO MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT NO. <br /> . EH 1324 It1Ev.riM5l <br /> EH;t•2a g. LO V w <br /> C <br />