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02/27/2006 08:26 464013P ENVIRONMENTAL N—I_TH PAGE 01 <br /> - APPLICATION _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION7- <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby mads to Baa JoARu1n County for a perikit to construct and/or inatau the work herein described. Thlc <br /> application is made in comilance with Own Joaquin County Ordinance No. 5L9 and 1862 and the Rules and Ftesulatione of Sen <br /> Joaquin County Public Health viServices. <br /> Job IX, lJhAddress �� 6V�U, ,lE I%gz City — Lot 8ize/Acreage <br /> Owner's Name �''f�""' Addross _�97/J�.. _ Phone <br /> Cbnlraclor Address.%i License Noof".?'-3 Phone <br /> TYPE OF WELL/PUMP: NEW WELL C WEII REPLACEMFNT n DESTRUCTION C) Out or Service Well ❑ <br /> PUMP INSTALLATION D SYSTEM REPAIR C') OTHER ❑ Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> s <br /> FOUNDATION AGRICULTURE `NELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f1 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Oia of Well Caging <br /> C i;Domesilc/Private 0 Gravel Pack I.] Tracy Type of Casing__` Specifications <br /> I'I.Public Ill Other U1 Dolts Depth of Grout Steal Type of Grout U` <br /> I I'Irrruauon .,—.Aporoa. Depth I I Eastern Surfsce Seel Installed by r <br /> Repair Work Done ❑ Type of Pump _ WP, Stele Work Done _ <br /> V411 Destruction O Welt Diameter Sealing Material Depth <br /> Depth Filler Materiel 6 Depth <br /> TYPE OF SEPTIC WORK- NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCrTON 1 N Ceoifif System jiWi-Mirr.di it public sewer Is <br /> available within 200 lest I <br /> Installation will serve: Residence _L_ Commercial _ 0!her <br /> Number of living Unita: __/_ Number of badro0 s '21 .1 , <br /> Character of sod to a depth of 3 reel: Wager table depth <br /> SEPTIC TANK O Ty0a71Mfp &itILL Capacity l� No. Compartments <br /> PKtG. tREATMFNT PLT. ❑ Method of Disposal <br /> Distance to nearest: We'I Foundstion Property Line <br /> LEACHING LINE r1 No, b Length of lines — Total length/size <br /> FILTER BED cI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Dapth Sire ._ Number L <br /> j , <br /> SUMPS 1.1 Distance to nearest Well �__ Foundation _ Property Lina <br /> DISPOSAL PONDS 0 <br /> I hereby comity that I have prepared_this.applicat,on-and.that.-the.work_will_be.dome m..aoeordoncs YVI(d San Joaquin county ordinances, stere laws, and <br /> rules and regulations of the San Joaquin County II <br /> Home owner or licensed agent'■signature cenifias tho following: "I certify that in the performAnce of the work 10, which this permit is issued, I shell not <br /> employ sny poison In such merino, as to become subject 10 workmen's compensation laws of California " Contractor's hoing or sub contracting slprleture <br /> cerhfiss the following: "I certify that in the performance of the work for which this permit is issued, shall employ persona subject to workmen's compensa <br /> tion laws,of California." <br /> The •ppllcs mu call for all r tri ad Inspec ort. Complete drswin6 on reverse slide_ <br /> Signed XTitle: d� � Date: <br /> OR ENT USE ONLY <br /> Apbficstlon Accepted by Date- --• Area.--,.©'�• <br /> Pit or Grout Inspection by Det, Flnel Inspection by '� / - Date L� <br /> Additional Comments <br /> Applicant - Return all copies to: San JOnquln County Public Health 8ervic�n <br /> Environmental Henith Permit/ServicoA <br /> don N SRn Jonquln, P 0 Brix 2006, Stkn, CIA 95201 <br /> FEE CrC RECEIVED Illy DATE PE�TN <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> CF.a <br /> INFO <br /> /py �7 7rte, <br /> FM 1�10 <br />