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F•'' APPLICATION FOR PERMIT i <br /> >I• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> r, ENVIRONMENTAL HHALTH DIVISION <br /> 445 N SAN JOAQUIN PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT-EXPIRES 1. YEAR FROM <br /> (Complete in Triplicate) 11i <br /> Application is hereby made•to San Joaquin County for a permit to construct and/or install the work herein described. This I <br /> application Is made In coWliance with San Joaquin County Ordinance No. 549 and 1862 gad the Rules and Regulations of than <br /> Josquin County Public Health Services. <br /> Job Address ` ! ��.+'�rr�°-'- City Lot Size/Acreage <br /> { a �,lf /V.// <br /> owner's Nanta � Address hone , <br /> -a� <br /> C1bnEracta � � Address� icense No. Phone-' <br /> i <br /> TYPE OF WELL/PUMP: • NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR' OTHER ❑ Monitoring Wt11 ❑ <br /> j 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 /> ❑Industrial O Open Bottom ❑ Manteca Dia- of Well Excavation Dia.of Well Casing <br /> Cl Domestic/Private 0 Gravel Pack © Tracy Type of Casing Specifications I <br /> 11 Pi+bk fl Other fl Deita Depth of Grout Seal Type of Grout <br /> iy!Irrigatiar► <br /> —.Approx. Depth t I astern Surface Seal Installed by { <br /> Repair Work Done 0 Type of Pump H,P,, :rDka _ State Work Done <br /> Well),Destruction ❑ Wap Diameter Sealing Material A Depth .,.. � � /�/ <br /> Depth filler liateritl i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo siptic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence.,,^, Commercial— Other t <br /> Number of living units: Number of bedrooms <br /> Character of sop to a depth of 3 feet: ' Water table depth V1 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT.❑ �+ Mathod of Disposal n l <br /> Distance to nearest: Well Foundation Pic�erty Line <br /> LEACHING LINE Cl . No. b Length o!lines Total length/size t I O <br /> FILTER BED 0 Distance to nearest: Well Foundation PtopertY line <br /> r <br /> -SEEPAGE PITS ! I . Depth Sue Number <br /> SUMPS LI Distance to neatest: Wap Foundation Property Lins <br /> I . DISPOSAL PONDS © ir <br /> I hereby certify.That i have prepared this application and that the work will be done in accordance with San Joaquin Cnunty ordinances, state laws,and IZ�o <br /> rules and rt <br /> rne gulai4ft of,the Sen Joaquin County • • t <br /> Hoowrw or Iresnsed s}leriYs signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ stly person in such-manner ati:to;become subject to workman's compensation laws of California." Contractor's liifuig or sub-contracting signature <br /> certifies the following:"I certify that in the prirformsncs of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> don laws of coliform", , G <br /> The applicant u' • i cilnru�. Complete drawing on rev nwside. s\ I <br /> Signed Datt <br /> _ e: <br /> , 'FOR DEPARTMENT USE 04Y <br /> Application Accepted by ---'Gr�l�C4h1 jl�A • �� Data E tt Aro, OZ l,� �•,"`L <br /> Pit or,Grout inspection by Date' Final Inspection by Date <br /> Comments- Q- <br /> 'Applicant - Return all copies to,: eaa Joaquin County Public Hee th services <br /> Hnvironmental Health Permit/Services l <br /> >+N .445 N bas Joaquin, P O Box 2009, Stlta• QA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED' CA81i RECEIVED 9y DATE FERMIT'HO. <br /> EM 14.76 <br /> • f <br />