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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONXENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES FROM DATEISSUED <br /> h j (Complete in Triplicate) <br /> Application is hereby made to San.Joaquin County for a permit to construct and/or install the vork herein described. This <br /> epplicstion is made in compliance,vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services. <br /> Cit t Size/Acreage <br /> Job Address <br /> J5dressPhone <br /> O er's Nam <br /> 0 I se No. Phone <br /> tEortl C or TI N 1=1 Out of Service well O <br /> TYPE OF WELL/PUMP:` l NEW WELL O WELL REPLACEMEN ❑ DESTRUC O Monitoring Well O <br /> j PUMP INSTALLATION SYSTEM REPAIR © OTHER O <br /> [[[ DkSPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> IIVTEI3DE�3 USE- 1, TYPE-Of-WELL=PROBLEM AREA—CONSTRUCTION-SPECIFICATIONS <br /> Dia. of Well Casing <br /> n I dusinal O Open Bottom C1 Manteca Dia. of Well Excavation ` Specifications- <br /> T of Casing- N <br /> mastic/Private 0 Gravel Pack C] Tracy Type q-, i Mrd;._ <br /> ! i- a Ic i 1-1 Other^= n Dega--�- ' Depth-of-Grout-Sept-' <br /> Type- f Grout-� <br /> l I Irrigation Approx. O I k E stern <br /> t1 ytrfaca Seal Installed by ` <br /> Repair Work Done Us d <br /> IJ Type of Pump i H P State Work <br /> 'Sealing Material i Depth 71 <br /> Well Destruction ❑ Well Diameter <br /> Fidler Material A Depth ry, <br /> Depth ,.] <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ/REPAIRlADDITION I I DESTRUCTION I i INaikseperwilhitern 200 emitted if public sower is <br /> Installation will serve: :Residence Commercial �� Other <br /> . � 1 <br /> Number of living units: Number of.bodrooms <br /> Character of soft to a depth of 3 feet r �' % Water table depth- <br /> SEPTIC TANK E� Type/Mfg--. Capacity No. Compartments <br /> PKG. TREATMENT PLT.O -r' Method of Disposal <br /> I Distance to nearest: Well Foundation Property Line <br /> . .: <br /> i LEACHING LINE C1 No. 8 Lengtli of linea Total length/size `%tf <br /> FILTER BED Cl Distance to nearest. Well Foundation Property Line <br /> I � <br /> Number <br /> SEEPAGE PITS l 1 Depth Sire <br /> SUMPS 4Ul Distancetto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 10 <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 taws, and <br /> rules and regulations of the Son Joaquin County, <br /> Home owner or licensed agent's signature certifies.thwfollo4ng: "I certify 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•become subjecthto workman's compensation laws of California."Contractor's Hiring or sub contracting signature <br /> f certifies the following: "I certify tKai in the performance of the work for which this permit is issued, I shall ern'oloy persons subject to workman's compensa- <br /> I tion laws of CMifornla." _ _, �- <br /> The applie t <br /> Itt", <br /> fo I squir Inspections. Campleta drawing on raver Ida. - <br /> Title: Date: <br /> I Signed -r <br /> OR DEPARTMENT USE ONLY <br /> by Data <br /> Application Accepted a <br /> Pit or Grout Inspection by Date Final Inspection b Data✓ <br /> Additional Comments. <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Boz 2009, Stkn, CA 95201 <br /> I <br /> I FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEDMA <br /> RECEIVED By DATE PERMIT N0. <br /> � Z_ 9�EH 11-24 IREV.+�K%I i' LQd r� <br /> EH 1626 l l <br />