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APPLICATION FOR ..PER✓i6I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> o <br /> Pep&,�� (Complete in Triplicate) <br /> Application is hereby mada,'to Sen Joaquin County for a permit to construct and/or install the Work herein described. This <br /> aquin Cc ty Ordinance No. 549 and 1 62 and the Rules and Regulations of Ban <br /> application is made in compliance with San Jo ; <br /> Josquin County Public Health Servicea. C <br /> l�! City ( Lot Si /Acreage <br /> .lob Address Uce <br /> :Add,o-s <br /> a O hone <br /> Owner's Name "� Addres <br /> { e License NoR2 Pho� <br /> Contractor <br /> TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIDN ❑ Out Monitoring Well i7 <br /> SYSTEM-REf?AIR.' -� POTHER ❑ <br /> PUMP INSTALLATION ❑ "; �._.„""�"�",.. � �� '" <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED.USE t TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '. Dia. of well Casing <br /> n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ; <br /> -Type of Ca, Specifications <br /> Domestic/Private.; ; Cl Gravel Pack: .$.k❑ Tracy g• r Type of rout <br /> CI Public I:l Other � L; � ❑ Delta Depth of Grout Seal ' <br /> G Irrigation _.._;App o.-DeptH Eastern Surface Seal Installed by <br /> < H P. State Work Don <br /> Repair Work Dane )rl Type'of P�mp Sealing Material i Depth t <br /> Well Destruction O Well Diameter <br /> l Filler Material b Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION 0 DESTRUCTION Cl (No sepeivrithin 200 rented if public sewer is <br />'4 Installation will serve: Residence - Commercial Other <br /> Number of living units. L" _'� ,Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> o <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal s <br /> i Distance to nearest: Well Foundation. Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED CI= Distance to nearest: Welt Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size W" Number <br /> SUMPS LI Distance to nearest: Well Foundation^ 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 San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "I comity that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as-to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> k certifies the following: "I certify that in the.performance of the work for which this permit is issued, I shall employ persons subject to workman's Compens8• <br /> tion laws of California." <br /> The appy+ ust call for all require inspecti . Co plate drawing arse side. <br /> Title: Date: <br /> Signed <br /> F DEPARTMENT USE ONLY <br /> R Date 2-w Area <br /> Application Accepted by <br /> oat J <br /> Pit or Grout Inspection by Date Final Inspection by <br /> { Additional Comments: <br /> Applicmt Return all copies to: TH SERVICES <br /> ENVIRONMENTALCOUNTY JOAQUIN HEALTHUDIVISIONBLIC LPERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT ptJE AMOUNT REMfTTED CASH <br /> INF <br /> r rEH13-74IREV.I K5) O� \\L. -kLA--q0 �� T <br /> EH 4.311 <br />