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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION {` <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 j <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERM T EXPIRES 1 YEAR R M D TE U :Q��,f.. <br /> (Complete in Triplicate) <br /> Application is hereby made to San Lavin County for a permit toconstruct9aa/or install <br /> i2 and the the <br /> Rules work <br /> herein <br /> and described. <br /> ThiBans <br /> rap <br /> application is made in coliance.vith San Joaquin County Or <br /> Joaquin county Public,Health Sery ea. <br /> City. Lot Size/Acreage <br /> Job Address . <br /> SM Address Phone <br /> Owner's Na _ <br /> Contractor "` <br /> o, ddress 'cense No. Phone <br /> k NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: OTHER ❑ %onitoring Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES 6ISPQSAL FLO. PROP. LINE - <br /> FOUNDATION AGRICULTURE WELL OTHER WELI'_ PITS/SUMPS -• <br /> INTENDED USE TYPE OF 1i11ELL PROBLEM A CONSTRUCTION SPECIFICATIONS Oia. of Well Casing <br /> n Industrial C3Opsn Bonom ❑ Manteca Dia. of Well Excavation Specifications,.. <br /> Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing_ <br /> Depth of Grout Seal Type at Grout <br /> I'1 Public I1 Other 11 Delta <br /> I I Irrigation —.Approx.}Depth I I Eastern Surface Seal Installed by <br /> of Pump - H.P. State Work Done <br /> Repair Work Done L] Type Sealing Material i Depth <br /> Well Destiuction ❑ Wall Diameter1111er Material i Depth <br /> Depthpuco <br /> TYPE K;OF SEPTIC WORNEW INST�ALLATION I I REPAIR/ADDITION i STRUCTION I I avaed ilabe within 200 feet. �I <br /> septic system lblic sewer is <br /> Installation will serve: Rest nce Commercial Other <br /> Number of living units;depth Number of bed m11 UJ <br /> Character of 90M to a dh of 3 feet:1 t 54'II`j Water table depth <br /> j <br /> SEPTIC TANK. ❑ Type/MfgCapacity No. Compartments <br /> ', <br /> + Method of Disposal <br /> PKG. TREATMENT PLT.0 I <br /> Distance-to.nearest:,W..eli, � _Foundation r Property Line — <br /> A <br /> LEACHING LINE �:1�lYv b Len gth of lines <br /> 5G 6L Total length/size <br /> �� <br /> FILTER BED ❑ Distance to nearest: Well Foundation�Q^ ,Prroper;y L!ne - <br /> t ist. l w i <br /> k _Size Number <br /> SEEPAGE PITS J`i�Depth <br /> SUMPS Ll 'Distance to nearest: Well !Foundation- •Property Line <br /> DISPOSAL PONDS ❑ _ _ T t <br /> I hereby Certify that I have prepared this application and that the work will be done in acco nce with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin county 1 <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 /> becoine a0 ect two <br /> d rkman's_compensation-taws of California." Contractor's hiring or sub-contracting signature <br /> empty any person in such manner as to <br /> certifies the fosowing: "I certify that in a peAormance of.the work fur which this perrnit i iaued, I shall employ persons subject to workman's compensa• <br /> tion of CalifOr <br /> The ics ust c II for req red ' pact' Complete drawing on versa aid _ ` <br /> t <br /> Title: Date: <br /> rD <br /> FORDEPARTMENT.USE ONLY <br /> Date Area <br /> Applicifion tep4ad by R ' <br /> I Date r� <br /> Pit or Grout Inspection by Date — Final inspection by <br /> 4 /43 <br /> Additional Comments: _ <br /> ,....,„.Applicant, -Return-all-copies-to:^-San 3oaqu3•e�'County-Pub1•i�e Heal'th`•Servi'C•-Is. <br /> Environmental Health Permit/Services r <br /> 445 N San'Joaquin, P D Hoz 2009, Stkn, CA 95201 <br /> FEE CK RECEIVED By DATE PERM17'NO. <br /> INFO AMOUNT DOE AMOUNT REMITTED CASH <br /> . EH 11.14 111M IIIl5l `nom-.a U� 1 03 L <br /> EH 11•ze - t <br />