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APPLICATIO14 FOR PEPWIT ; <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � <br /> ENV IRONN[ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> ERidIT E%PIRTsS <br /> ,EAR FROM D T U <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made <br /> e inl3comtliancei with San Joaquin county,ordinance No. 549 and 18 2 an�e Rules and Regulations of San <br /> Joaquin county <br /> A/, City , 7v7�•4l Lot Size/Acreage <br /> Job Address s <br /> r 5 I Address ?1 Phone <br /> Owner's Name ' <br /> � Y7�L/� �-� License No. Sa`�G Phone pis 3yy/ <br /> Contractor Address <br /> WELL REPLACEMENT ❑ <br /> E ODESTRUCTION Ll out of Service hell ❑ <br /> TYPE WELL/PUNEW WELL ❑MP: OTHER ❑ Monitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 f <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _-- - PIT5/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br />' #INTENDED USE TYPE OF WELL PROBLEM AAREEA CONSTRUCTION SPECIFICATIONS Dia:of Well Casing <br /> C7 Industrial ❑ Open Bottom ❑ Manteca .Dia. of Well Excavation Specifications- - <br /> I f.] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ <br /> �l Delta Depth of Grout Seal _ Typ Ilk Grout <br /> ['1 Public 1"1 Other <br /> I I Ifrigation —Approx. Depth I I Eastern Surface Saul Instalied by <br /> ofPump_ H.P. State Work Done <br /> Repair Work Bone U Type _ --- -^ <br /> Sealing Material i Dcpth <br /> Well Destruction O Well Diameter Filler Material i Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I' REPAIRIADDITION DESTRU BION 1 1 (No perml <br /> avas ptile w shin m leatpermit)ed if public server is <br /> Installation will serve: Residence 2Cornmerci8l— Other --F <br /> Number of living units: —/L Number of bedrooms O <br /> d` Water table depth <br /> r �Chwactaf of soil to a depth of 3 foot: <br /> X 1 S�.�(T '° Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/.Mfgr_ Method of Disposal <br /> -PKG. TREATMENT PLT. ❑ " <br /> Distance to nearest: Well� Foundation Property Line �( <br /> LEACHING LINE 'a NoLength of linea " v -- — Total Length/size O <br /> - FILTER BED 0 Distance to nearest: /Wali. /O4r - <br /> Foundation Property Line--gar-2- <br /> \ <br /> SEEPAGE PITS l DepthT Z -Size — . ' Number <br /> SUMPS LI Distance to nearest: Wall Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "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 subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature <br /> 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 compensa- <br /> tion laws of California." <br /> The,applicsnt must call for all required inspections. Complete drawing on reverse side. <br /> Sig nsd Title: _ Data: <br /> FOR DEPARTMENT USE ONLY <br /> { DateAreaA <br /> Application Accepted by <br /> Data <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services \ � <br /> Environmental Health Permit/Services �J�Q,' <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> i• FEE K RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DVE AMOU T REMITTED <br /> /10Z <br /> + fN 1]-24 MEN.t/MSI <br /> EH 14.76 <br />