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I ` APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONIENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br />} P O BOX 2009, STOCKTON, CA 9520JL <br /> PERId T EgP I RESI YFuFR A[ DTE <br /> t (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 ia'made in eoapltanrvices. <br /> cewith San Joaquin County ordinance No. 549 <br /> Jasquin County'Public Health Seand 11362 and the Rules and Regulations of San <br /> Job Address ✓ City Lot Size/Acreage <br /> Owner's Name L j+ NlOddress <br /> Phone <br /> Contractor Address <br /> 1 License Nof Phone D <br /> TYPE OF ELL/ UMP; NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 ; OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DlSPQSAL FLD. PROP. LINE <br /> FOUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing � <br /> Cl Domestic/Private ❑ Gravel pack: ❑ Tracy Type of Casing S <br /> I.1,Public C1 I 1 Other (1 Dena Depth of Grout Sear Type Of Grout <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by. <br /> Repair Work Done U Type of Pump H.P. <br /> State Work Done ( , <br /> Well Destruction ❑ Well Diameter f Sealing Material i Depth i <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I Ir REPAIR/ADDITION I I DESTRUCTION 1 1 (No septic system permitted if <br /> ++ pe public sewer4i& <br /> Installation will serve; Residence 1 Commercial_ Other available within 200 feet.!�4�Number of living units: Numbeiof�edroome -.� --{ \\A` <br /> Character of soli tea 15 E <br /> depth of 3 feel: Water table depth <br /> SEPTIC TANK. ❑ Type/Mig.- - I r t Capacity i <br /> PKG. TREATMENT PLT.❑ . 1- ---- No. Compartments <br /> J k Method of Disposal <br /> Distance to nearest:` ;Well dQ' <br /> _} 1 /� Foundations Property Line R <br /> i <br /> LEACHING LINE ❑ No. & Length of linea <br /> i Total length/size <br /> FILTER SED ❑ Distance to ne1 <br /> .�.�� Foundation-,S�•�, Property Lineys <br /> Iarest: Well d <br /> SEEPAGE PITS 11 th� Size <br /> SUMPS Number_0_ <br /> Ll Distance to rtsarsst: Well` Foundation VQ Property Line <br /> DISPOSAL PONDS ❑ "v. X 0 O X S <br /> ""' r <br /> f hereby certify that 1 have prepared this application and that the work will ba done in accordance with S <br /> rules and regulations of the San Joaquin County an Joaquin county ordinances, stats laws, and <br /> Home owner or licensed agent's signature certifies the following: '1F �_n ... <br /> 'iI certify that in the performance of the work for which this permit is issued, I shad not <br /> employ any person in such manner-as 10 become subject to workman's compensation laws of California."Contractor's hiring Or sub-contracting signature i <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 Iaws of California." - . <br /> Thea • <br /> Pplicant ffvst cad} ail r u Inspection Co plate drawing on reverse side. <br /> Signed <br /> Title: 14&2jf � <br /> ' Date: i <br /> DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Oats Area <br /> Ph or Grout Inspection by Date Final Inspection by I <br /> Dots <br /> Additional Comments: <br /> 0 a Applicant - Return all copies to: San Joaquin County Public Health Services T;to,# <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE � AMOUNT REMITTED CK RECEiVEO BY <br /> D TE PERM17'NO. 4 <br /> EH 13-24 <br /> EM 11.2A <br />♦ IREV,r/K�1 .O ' , <br /> it <br />