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r � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONKENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> I <br /> PERMIT EXPIRES I YEAR FROM- DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Sau Joaquin County for a permit to construct and/or install the vork herein described. This <br /> application is made in eo4liancetivith Ban Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> � <br /> Job Address aww, S1r City Lot Size/Acreage <br /> 4 Phone ;' <br /> Owner's Name 1. Address�Y 7 [C ���[ vli"��-4yti � <br /> Contractorkia L Address GRoirLac" ansa Phone <br />` TYPE OF WELL UM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> F — <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR b OTHER ) Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca ; Dia- of,Well`Excavation Dia. of Well Casing <br /> Domestic/Private_. ❑ Gravel Pack ❑.Tracy Type of Casing_ Specifications <br /> I I'l Public (:1 Other 1-1 Delta Depth of Grout Seal ^ Type of Grout <br /> I I Irrigation T.Approx. Depth I I Eastern ,,'' Surface Se}}���n Called by <br /> Repair Work Done Type of Pump;,0.� H.A. fez, �d. I, _ State Work Done P <br />` Sealing Material i Depth a z <br /> Well Destruction ❑ Well piameter� <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-1 11 REPAIR/ADDITION 13 DESTRUCTION I l lNo septic system permitted if public sewer is 1ti1�\\F <br /> k - available within 204 feet.] <br /> F" Installation will serve: Residence h. Commercial_ Other <br /> Y Number of living units: Number of bedrooms v r <br /> Character of soil to a depth of 3 feet: - efl �dcr <br /> SEPTIC TANK. r ❑ Type/Mfg _ 'Capacity V �" " " <br /> PKG. TREATMENT PLT.D <br /> Distance to nearest: Well Foundation ProperNM9 1993 <br /> SAN jGAOU IN 60UNT-Y <br /> LEACHING LINE ❑ +No. 8 Length of lines - Total iefMC <br /> FILTER BED ❑ Distance to nearest: Well Foundation FNIgQWEwA.HFA .1H niVISION <br /> SEEPAGE PITS I I Depth I} Size Number <br /> ,;,SUMPS_. Ll, placenta to r►sanst: Well - by Foundation -- " Property Line <br /> �.� <br /> DISPOSAL PONDS ❑ <br /> I hereby canify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County -" -%�is is <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit isubd I shall not <br /> employ any person in such manner as to become subject to workman's compensation Iowa of California."Contractor's hiring or sub-contracting signature <br /> cenifies the following: "I canify that in the'psrformance of the work for which this permit is issued, I shall employ persons subject to workman's compansa,: <br /> tion laws of California." <br /> + <br /> The applicant at cell for all uired inspections. Complete drawing on raver ide. <br /> Signed ' Title: pate: <br /> 0 PART T USE ONLY <br /> Application Accepted by- Date � ,;0�-XArsa <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> r <br /> Additional Comments: # <br /> 1 <br /> Applicant - Return all copies to: San Joaquin County Public.Health Services <br /> Environmental Health Permit/Services <br /> 446 N San Joaquin, P O Box 2009, Stkn, CA 95261 <br /> FEE <br /> INFO MOUNT DUE AMOUNT REMITTED rrA RECEIVED 8Y DAT PERMIT'NO. <br /> • EH 13-24[REV.rifts <br /> EH 1440 <br />