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2 <br /> APPLICATION FOR PERMIT <br /> SAN JO QUIN COUNTY PUBLIC HEALTH SERVICES R <br /> ENVIRONMENTAL HEALTH DIVISION <br /> -1601 E. HAZELTON AVE. , PHONE (209)468-3420 SEP 1 7 1992 <br /> P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH <br /> PERMIP EXPIREs 1 YEAR FR nu naTE ISSUED PERMIT15ERVIUS <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. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. - <br /> Z / /ar , ^ of <br /> 412 // /e/� city Site/Acreage <br /> Job Address <br /> Owner's Nama <br /> � Address .Z Phone <br /> Contractor Address <br /> �,/ j )r/, rt seNp. ?5/S7 ti: Phone - 6 <br /> NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of one, <br /> Well ❑ <br /> TYPE OF WELL/PUMP: <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well LT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of CasingSpecifications <br /> )4 Domestic/Private ❑ Gravel Pack ❑ Tracy YP Type of Grout <br /> CI Public 1-1 Other fT Delta Depth of Grout Seal <br /> I I Inigalion _Approx. Depth I I Eastern Surface Soul Installed by H.P. ! )z'G <br /> Type of Pump State Work Done F <br /> er <br /> Repair Work Done )QTypeMaterial L Depth lef ��� 7 <br /> Well Destruction ❑ Well Diameter '-Filler Material a Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I availaseptic <br /> systele shin m emitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other \ <br /> Number of living units: _ Number of bedrooms C2,Water table depth (t. <br /> Character of soil to a depth of 3 feet: U1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ � <br /> Distance to nearest: Well Foundation Property Line <br /> t\ <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number r\� <br /> Property Line <br /> SUMPS LI Distance to nearest: well Foundation <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <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 laws of California." <br /> The applicant ust all for I requir in coons. complete drawing on reverse side. <br /> Signed X__c6lg4 <br /> Title: - /Ma L/ Date: T <br /> i 100 <br /> FO P T USE ONLY <br /> Date A a " <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Dat Z <br /> Additional Comments: - <br /> Applicant - Return all copies to: San Joaquin County Envi opmenutaliHealthtPermlt/ServiceServs r <br /> �--` 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> u <br /> FE <br /> AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO, <br /> IN AMOUNT DUE <br /> . EM 13-24 IREV.1/x5i <br /> EM 14-M <br />