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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUBTTY PUBLIC HEALTH SERVICES PAYMENT <br /> ENVIRONIMTAL HEALTH DIVISION RECEIVED <br /> `445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 NOV 2 3 1992 <br /> SAN JOAQUIN COUNTY <br /> PERMIT .EXPIRES 1 YEAR FRQN DATE ISSUED p;JOL;C HEALTH SERVICES <br /> (Complete in Triplicate) CNIRONMENTALHEALrHpiVIS*r. <br /> Application Is hereby tade to San Joaquin County for a permit to construct and/or 1notal.l the work herein described. This <br /> application Is tendo in co.ryylinnce with San Joaquin County Ordinance No. 549 and 1962 and the Rules and Regulations of San <br /> Joaquin- County Public Health Services. Rd. _ City Lot Size/Acreage <br /> _ . <br /> Owner's Nome Address `,4 1 o0rte' , , ♦' �Phone <br /> Contractor l, Address License No.Avu Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELT REPLACEMENT rV DESTRUCTION O Out of Service Nell O <br /> PUMP INSTALLATION TO 1SYSTE M REPAIR 1W OTHER O "onitoring we" O <br /> DISTANCE-TO NEAREST:'SEPTIC TANK � SEWER LINES DISPOSAL FLO. PROP. LINE <br /> ` F0UNDAf1014 -"" AGRICULTURE-1rVELL't't' ' �-OTHER WELL PITS/SUMPS- <br /> -INTENDED USE TYPE OF WELL PROBLEM AREA LCONSTRUCTION SPECIFICATIUNSF <br /> n Industrial O Opon Bottom• �.�^-O Manteca—pia. of Well Excavation Dia. of Well Casing <br /> Domoetic/Private O Gravel Pack/ O Trasy.— ­.,----Type of Casing_ Specifications <br /> ,.:.-r- <br /> I'] Public n Othm-' y'fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigat `:r; ? ApproxeDepth 1 I I Eastern Surfaco Soul installed by <br /> Ropoir Work Donal U T�i f Pump H.P. i State Work Done <br /> r <br /> Sealing 2hterial'b Depth <br /> Wb11 Doatnrction -'-•-,p/WONOiametor , <br /> i�Jy j Depth b s Filler Mterial b Depth <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION I 1 REPAIR/ADDITION I I �p'ESTRUCTiON I i INo septic system permitted if public sewer is <br /> available within 200 teol.1 <br /> Installation will servo: Recidenco Commercial_ Other <br /> Number of living unita: Number of bedrooms <br /> Character of cog to a Q�pth of 3 foot:. Water tabkr depth <br /> SEPTIC TANK. O Typo/Mfg' Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Diatenco to nearest: Well Foundation Property Lino <br /> LEACHING LINE O No. A Length of lines Total length/size <br /> FILTER BED O Distance to nooroat: Watt Foundation Property Line <br /> Tr + <br /> SEEPAGE PITS 11 Depth Size Number {' <br /> _SUMPS.. <br /> L) to rrsr .WOOS. Fdunaation Propor.ty_Line. - \ <br /> a DISPOSAL PONDS O ^G f <br /> I horoby certify that I have prepared this japplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rulos_and regulations of the San Joaquin County 1 <br /> Noma ownor or licenacd agant's i dgnatufc eortifisa the following: "I certify that in the performance of the work for which this'pormit is iasued,I shall not <br /> employ any par `-such manner as to jbecomo eubisci to workmen's componsation Iowa of California."Contractor's hiring of sub-contracting signature <br /> cortitioa the f 1 certify that in thb porformonco of the work for which this permit is issued,I shall employ persona subject to workman's compenoa <br /> tion louva Cal 'i fir\_ 1 <br /> -Tho applies t call for cl r' od iris ons. Complete drawing on reverse side.nil <br /> Signod Title: U 1' <br /> Dates <br /> FOR DEPAFITAREN USE ONLY <br /> Application Acceptod by Date 'Area � <br /> Pit or Grout Impaction by Date Final Inspection by Data �3 <br /> Additional Commonta: f• 1n- -- <br /> Applicant - Return all copies to: San Joaquin County"'Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEE A OUNT DUE AMIT <br /> AMOUNT REMTED K ECEI D BY ATE PERMIT'NO. <br /> INFO <br /> > i <br /> M s ..r <br />