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APPLICATION FOR PERMIT OL-b Loi-oigleco-t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> � P 0 BOX 2009, STOCKTON, CA 95201 { <br /> ERMIT EXPIRES1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> her <br /> in <br /> Application in r install <br /> work <br /> application is made in comwillance.�vltSan h San Joaquinocounr a ty Ordinance rmit to nNo. 549struct a and1862d the Rules mdaReguletloneof San <br /> Josquin County Publlc,Health Seryes. < <br /> City Lot Size/Acreage <br /> Job Address !!JJ tau <br /> Phone <br /> i <br /> Ownes NemrF Address c <br /> vicense No. Phone J <br /> Contractor LIJ (.� d V ddress <br /> NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out Nonitoring Well <br /> ❑ <br /> TYPE OF_ V`/ MP' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLO. PROP. LINE _— <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES OTHER WELL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ma. of Well Casing <br /> nom ❑ Manteca Dia. <br /> ❑ Industrial ❑ Open Boof Well Excavation Specifications <br /> ❑ Domestic/Private ❑ GravelPack L1 Tracy of Casing_Tracy Depth of Grout Sea Type of Grout <br /> M Public (71 Other � n Delta <br /> I I litigation _Approx.`Depth I I Eastern Surface Soul Installed by <br /> of Pump <br /> H.P. State Work Done_ <br /> Repair Work Done Ll Type Sealing Material i Depth <br /> Well Dntiuctbn ❑ Well Diamstai <br /> Depth1 Tiller material a Depth <br /> ystem R TYPE OF SEPTIC WORK: NEW INSTALLLAATION I 1 REPAIR/ADOI LION I STRUCTION I I availabetic thin 2001eat��ed it public "vwr is <br /> Installation will sdma commercial Other <br /> G I^Wr of living units; Number of becir ms <br /> Num <br /> 1 f ,4 s( )Ct Srj&&t Watsr table depth <br /> Chwactor of wit to a depth of 3 1"t: _ •-. No. Compartments <br /> SEPTIC TANK- ❑ Type/Mfi Capacity <br /> Method of Disposal <br /> / PKG. TREATMENT PLT.❑ <br /> - Foundation- - Property Line <br /> -Distance.10 <br /> ' S0 .LL. Total length/size <br /> LEACHING LINE rl�FOo'. i_Lahgth of lines r rt J - <br /> FILTER BED ❑ Distance to nearest: Well I Z� Foundation.,a o py'Line <br /> ... � <br /> 1 <br /> SEEPAGE PITS �'I-�DeDth I S Size N robe. <br /> '� �Ar� <br /> SUMPS LI Distance to nearest: Well foundation�J.Al--.Property Lina <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and Thal the work will be done in accordance with San Joaquin county ordinances, state laws, on( <br /> rules and regulations of the San Joaquin County <br /> Home owner Or licensed agent's signature cariilles the following: "I certify that in the performance of the work for which th'ro permit is issued, I shall no <br /> of <br /> employ any person to such <br /> 'I cert manna <br /> thf as to e[n t psAo i� 01aGbiict the work fo•wh ch Ihu 1permiiion vs�isauedltI shalt employ persons subject o worrkractor's hiring or tman's ompensa <br /> certifies the following: ' fy <br /> ton of Calif <br /> The \ ice It for req red pecl. Complete drawing on ver" sid 2 � <br /> Date:-2 <br /> S _ Title: n <br /> 1^. F(IRD PARTMENT.USE ONLY <br /> _ �•�.:�"YK Area <br /> AppliZ'tion-7lccepi«I <br /> Data <br /> PN IT Grout Inspection by Date <br /> Final Inspection by <br /> Additional Canroente: " <br /> Applicant=-Return-al-l-copies-to:-Ban-Joaqu4e-County-Pu1rTYc"Maalth-ServTC' <br /> + Bnviz'oamerital Health Permit/Services n <br /> Yom. `-`445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASN RECEIVED aY DATE PERMIT'NO. <br /> INFO <br /> !N t11e tREv.r,.b. S72 I 1 lf ob_, 1/`P �� 1037 A- 3-Iv - 3-03 <br />