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APPLICATION FOR PERMIT YRI <br /> SAH .JOAQUIN COUNTY PUBLIC HEALTH SECES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX_ 2009, STOCKTON, CA 95201 <br /> . (209) 468-3447 i <br /> `j <br /> PERMIT EXPIRES 1 YEAR rRQIL_DATN IiSSUIQ <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. .'Thie <br /> application is made in compliancewith San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. at f <br /> ao . E -- [ <br /> City G Lot Size/Acreage <br /> Job Address i' <br /> Phone <br /> �9l4 <br /> Owner's Nims �l +� �' Address G�4/V D r �• <br /> Contractor. <br /> Tess License too. 17-Cor Phone �GS"$2IZ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C- DESTRUCTION ❑ Out of Service Kell C� <br /> SYSTEM REPAIR L OT ER [3AMonitoring Will n <br /> PUMP INSTALLATTIQ ❑ �/L 8prik 5 <br /> DISTANCE TO NEAREST: SEPTIC TANK:' /� �" SEWER LINES ' DISPOSAL FLO. PROP. LINE <br /> FOUNDATIONIIIAGRICULTURE WELL lYL. OTHER WELL=446L!+= PITSISUMPS -- s <br /> f <br /> iNTENOED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECtFICATlONS <br /> fl Industrial ❑ Open Bottom ❑ Manteca ' Dia. al We11 Excavation Dia. of Well Casing <br /> U Domestic/Private ❑ Gravel Pack ;, ❑ Tracy Type.of Casing �' `' Spscilications <br /> It <br /> M Public Cl Other ❑ Delta Depth of Grout Seal r I Type o} Grout <br /> G teriUauon Approx. Depth 0 Eastern Surface Soul Installed by <br /> Repair Work Done ❑ Type of Pump H;iP. State Work Done <br /> Sealing Material i Depth <br /> Well Destruction ❑ Weil Diameter >- { <br /> y ` <br /> Depth Piller Material i .Depth i a <br /> O. <br /> TYPE OF S IC WORK: NEW INSTALLATION 17 REPAIR/AOOITION'ZI DESTRUCTION G iNo saptrc iyslem permilled if public sewer is Q <br /> available within 200 feet.) <br /> instailation will serve: Residence— '�Commercial— Other <br /> Number of living units: Number.of bedrooms ' <br /> !; Water table depth <br /> Character of soil to a depth of 3 feet: v - , <br /> SEPTIC TANK. 13Type/Mfg Capacity - No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ 4f <br /> Distance:to nearest: Well Foundation Property Line v <br /> 'I <br /> LEACHING LINE C1 No. length/size <br /> No. & Length of lines " g <br /> FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth -Silo Number <br /> SUMPS { LI Distance to'Irnearest: Well `I Foundation Property Lisle . <br /> DISPOSAL PONDS ❑ <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 San Joaquin County ii <br /> Home owner or licensed agent's signature;certifies the following: "I certify that in the performance of the work'far which this permit is issued, I shall not <br /> employ any person in such manner as to b»come subject to workman's compensation laws of California." Contrdctor's hiring or sub-contracting signature <br /> certifies the following; "I certify that in the performance of thework for which this permit is issued, i shall employ,persons subject to workman's compensa- <br /> tion laws o! C ifornis." t <br /> The sppli nt m at call for all requir nspsctions. Complete drawing on reverse side. <br /> Signed Title: " Date: <br /> �i <br /> FOR IJEPAR7MENTUSE ONLY <br /> C/ <br /> Pit <br /> Application Accepted by Date `�O Area <br /> Pit or Grout Inspection by _-1` Date Final Inspection by . i,_ - _. Date 41 <br /> Additional Comments: <br /> Applic&nt - Return all copies to: !SAN JOAQUI COUNTY PUBLIC'HEALTH SERVICES L <br /> ENYiRONItF1i HEALTH DIVISION PERIdIT/SERVICES OD <br /> ii '443 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON; CA 93201 r <br /> V <br /> It IFEENFO AMOUNT DtJE AMOUNT REMITTED SM RECEIVED BY PATE IT''HO. <br /> X30 -fit <br /> ?`�Y <br /> . EM 17-24 iREV.r ire <br /> EM:d-2a , <br />