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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HE � <br /> ENVIRONMENTAL JIEALTH DIV <br /> r <br /> 445 N SAN JOAQUIN, PHONE 03420 <br /> 3420 <br /> P O SOX 2009, STOCKTON, 3 <br /> PERMIT F"IRES 1 YE R M <br /> DEC- <br /> (Complete in Tripli. a / <br /> Application is hereby sdde,to San Joaquin County for a permit to construct ie <br /> application in Inde in co�lisutce vith San Joaquin County Ordinance Ifo. 549 and 18 2 and t e es er neo n <br /> Joaquin County Public Health Services. <br /> Job Addle" _ �6 yrs Citvt-e=L= Lot Si:e/Acren,3e <br /> IL <br /> Owner's Name � t Address —___ Phone <br /> Contrattof T A t41 1- Addres� <� License No�i � Phone <br /> TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT D DESTRUCTION 1.1 Out of Service !Jell Ll <br /> PUMP INSTALLATION L] SYSTEM REPAIR Cl OTHER O <br /> Monitoring Well IZ <br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (.l tnduaviat O Open Bottom U Manteca Dig, of Wall Excavation_._ Dia. of Well Casing <br /> CI Domestic/Private O Grovel Pack O Tracy Type of Casing_.___ Specifications <br /> I'I Public I.] Other 11 Delta Depth of Grout Seal Type of Grout t) <br /> I I Irrivation Approx. Depth t I Eastern Surface Soul Insla!lod by <br /> Repoli Work Done L) Type of Pump H.P. _ Statp Work Done , <br /> Wet!Destruction 0 WON Dismeter Sealing Hateris.1 A Depth <br /> Depth Piller Material 1 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION i I lNo septic system permitted if public sewn+ is <br /> ,/ available within 20(3 feet.l <br /> Installation will serve: Residence F� Commercial_ that <br /> Number of living units:I Number of bedrooms _ <br /> Character of poll to a depth of 3 feel: Water table depth <br /> SEPTIC TANK O Type/Mfg t Capacity No. Compartments <br /> PKG. TREATMENT PLT.Cl fr'-7T f �-T Method of OisposaI 1 <br /> Distance to nosiest: Well h2aL Foundation Property Llno <br /> LEACHING LINE No. & Length of l,neo i = r, �� Tu�lal length/site ✓ <br /> FILTER BED Cl Distance to nearest: Wall,� ,t�Foundation _ Property Lino <br /> SEEPAGE PITS : 1 Depth F� Sire Number <br /> SUMPS )`< Oistance to neatest: Wail /30,`— Foundation Zai j`, Property Lina ^° <br /> DISPOSAL PONOS O <br /> 1 hereby canity that i have prepared this application and that the work will be done in accordance with Stn Joaquin county ordinances, state taws, and <br /> rules and rogutalkwA of the San Joaquin County <br /> Home owner or licansad ageni'a krimure cenifies the lollowmg: "I certify that in the performance of the work for which this permit is loved, i shall not <br /> employ any person in such manner os to become subject to workman's compensation laws of Csfifornla."Contracror't hiring or sut}controcfing aignature <br /> certifies thio following:"1 certify that in the performanco of the work for which this permit Is issued,t shall employ perwns subject to workman's comp4nsa- <br /> tion I"of Csvlfomta." <br /> The applicant must call for dl i fired in cticins. Complete drawing on reverse side. <br /> Slgnad X__ � � Title: u ! Date: -25 '—Z <br /> FOR DEPARTMENT USE ONLY <br /> Applicwton Accepted by Row KkMo o Data ! .��•',el-5 Area JJ I o q <br /> Pit or Grout Inapeclion by Data Final Inspection by LT t�2 DatO 1� <br /> AddilionN Comments: <br /> Applicant - Return all copiea to: Ban Joaquin Crounty Public Health servlcee <br /> Eoviroomental Health Permit/8ervicee / /) <br /> 445 N San Joaquin, P 0 Sox 3009, atkn, OA 95201 V� 00FfE A <br /> INFO AMOUNT OUE AMOUNT REMITTED CAstt REC[rvEO 9y DATE PERMi?no. <br /> . CH tY24lkN.tree) if '• ��� �Ti �r lJ iJ�'! L', ✓ <br /> 1H 114.25 // I �'' 7• I'7 �3 /�D <br />