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I` APPLICATION FOR PERMIT <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DTE I <br /> ME& <br /> II (Complete in Triplicate) <br /> , <br /> Applicatioa is hereby made.to S J u1 CJ�uinocounr IL ty ordinance rmit to nNo- 549 and 1862aand the tall eRules anwork d Regulations of San <br /> d. 6 <br /> application is ma e 1 o <br /> Joaquin County 5 �gl ge 8E40e.N CAA%,p p Got Size/Acreage <br /> City <br /> ob Address pO d Zgs <br /> Owner's Name <br /> Address rQW�H 1� Phone l <br /> 11 s.License No. ---Phone <br /> Ilf ontractor_� ' Address ❑DE5TRUCTION Out of Service Well ❑ <br /> NEW WELL ❑ WELL REPLACEMENT -1Monitoring Well (3TYPE OF WELL/PUMP: SYSTEM REPAIR Cl OTHER ❑ <br /> PUMP INSTALLATION 0 DISPOSAL FLD. PROP. LINE V 1 <br /> ���— <br /> DISTANCE TO NEAREST: SEPTIC TANK ��-� SEWER LINES OTHER.WELL_ PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> 1NTEfV'DED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' Dia.`.of Well Casing <br /> Dis. of Well Excavation <br />' Cl Industrial ❑ Open Bottom ❑ Manteca _ Specifications:— <br /> Type of Casing_ <br /> [l Domestic/Private ❑ Gravel Pack L7 Tracy Depth of Grout Seal_ TYPe of GLou1 <br />` n Delta . <br /> l'1 Public!! Cl Other , <br /> r I I <br /> if( at' n ____'rApprox. Depth I I Eastern S ace Seal Installed by <br /> TypeofPump --- H.P. State Work Dane <br /> t Repair W�rk Done r t <br /> Sealing terial F Depth <br /> well Destruction O Welf!Diameter — i �, <br /> Depth 0 biller Material Depth <br /> TYPE OFISEPTIC WORK; NEW INSTALLATION i I REPAIRIADDITION f 1 DESTRUCTION 1 aNailablelwithin 200 feetstem lled tl public sewer is <br /> k; installslion will serve: Rasidence Commercial Other <br /> Numbsr of living units: �N Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No'Compartments <br /> 'SEPTIC TANK ❑ Type/Mfg Capacity— <br /> Method of Disposal <br /> PKG. TREATMENT PLT.Q ��. Property Line , <br /> Distance to nearest: Well Foundation <br /> i LEACHING LINE L1 No. a Length of lines <br /> Total length/size <br /> $ Foundation Property Line <br /> FILTER BED ❑ dDistance to nearest: Well t ea <br /> lSize Number <br /> SEEPAGE PITS - 1-I Depth Pro Line <br /> SUMPS: ll Distance to nearest: Well Foundation gem <br /> DISPOSAL PONDS ❑ <br /> 1 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 anis regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the perforof mance of the work for which this permit is issued, I signature <br /> shall not <br /> employ'#ny person in wl h manner as <br /> s to the performancesubject <br /> ofolhe woman'ork s compensation <br /> this ttionperto issued,!shall amploty persanstsubjecring rt to worktman1sc mpensa- <br /> cartifias:the following: '. <br /> tion laws of California." �p <br /> The applicant m call for allrequiredinspgctions. Complete drawing on reverse side. 2 Z+ d Z <br /> !T" _ TRW Date: f <br /> Signed� - <br /> [[[JJJ i F DEPARTMENT USE ONLY <br /> Ck Date 7-= rev <br /> Applicatlon Accepted by 4 <br /> II. Date�..—.�. Final Inspection Dat, <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> p <br /> Applicant - Return�j'all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, StRn, CA 95201. <br /> III <br /> K CEIVED BY DA E PERMIT NO. <br /> FEEFEE1 AMOUNT REMITTED C }{INFO �� <br /> . EK 13-24 IRtcil.t/Atli <br /> EH 14.36 <br />