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APPLICATION FOR PERMIT - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> "L � ' ENVIRONMENTAL HEALTH DIVISION <br /> We,a• 1f301 E. HBOXI,200 AVS. , PHONE C A 9)•468-3420 �1 Ply <br /> P O BO% 2009, STOC%TON. CA 95203. (�(�.J�Jl <br /> pEUIT EXPIRES 1 YEAR FROM L)AT.E_ISSUE <br /> (Complete in Triplicate) <br /> Application is heresy made.to San Joaquin County for a permit to c6netruct and/or install the cork herein described. This <br /> applice,tion•is made in Compliance with San,Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. Lot Size Ih <br /> `7.r h <br /> Job Address City creag 2� — <br /> Al 91,12 Phone j <br /> Owner's Nance Address <br /> R <br /> Contract _I!!.� t�l� l +-�!address � License,No'�`3��.... .. Phone T-' <br /> TYPE OF WECLIPUMPI NEW WELL WELL REPLACEMENT LJ DESTRUCTION D Out or Service well L� <br /> — 'I ,PUMP INSTALLATION V SYSTEM REPAIR El OTHER p Monitoring tical) O <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> •T-- DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ' TYPE OF`IWEI.0 PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L��lh/ndustrial pen Bottom' _. ❑ Manteca Dia. of Well Excavation [)is.of Well Casing <br /> III Domestic/Privets 0 Gravel Pack 0 Tracy Type of Casing w Specifications <br /> i'1 Public i ["1 Other .•'` El Delta Depth of Grout Seel Type of Grout 4Sctcr�t baRo�c <br /> } I I Irrigation A�,Approx. Depth I 1 Eastarn Surface Seal Installed by_ eA <br /> r Repair Work Done Olt Type of Pump � H.P. 2- - State Work Done <br /> Weli Destruction ❑ Well Diameter Sealing Material ft Depth <br /> . Depth Filler Material 6 Depth <br /> TYPE OF SEPTIC WORK: NfW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I t fNo septic system permitted if,public sewer is <br /> available within 200 feet.) , <br /> Installation wM_-sa Residence Commercial____ Other <br /> Number of living antis: bedrooms <br /> Character of soA to a,depth of 3 feet: Water table eptft✓y <br /> SEPTIC TANK. f0 Type/Mfg Capacity ompartmsnts <br /> PKG. TREATMENT PLT.0 Method of Disposal <br /> v Distance to nearest: Well �Founde' Property Line <br /> Nor <br /> it <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED �� 0 Distance to nears all }Foundation Property Line <br /> S SEEPAGE PITS i1 -' epih --��5i:e—� a Number J <br /> SUMPS I 0-Distance to nearest: WpN..� Foundation Property Lina <br /> DISPOSAL PONDS II © r <br /> I hereby certify'that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and+ <br /> rules and regulations of the San Joaquin County <br /> f 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 /> Thead Title:pplicant u 84 for all requir inspections. Complete drawing on reverse side. <br /> Signe �-- <br /> H t;7t r je n ea—t�- �.[11C+�'v Date: - 2 <br /> R DEPARTMENT USE ONLY <br /> b _ 1-3�--"� -- Area �-- <br /> r Application Accepted Eby :,r.r- . Date , - <br /> �� Date, _ Final Inspection by Date <br /> Pit,t,0 r Dro I InspectioA byr <br /> Additional Comments: <br /> Applicant'- Return all copies to: San Joaquin County Public Health <br /> A Services, Environmental Health Permit/Services <br /> 1601-E._Ha>re1ton_Ave.,._P- 0 Bax 2009, Stockton, -CA 95201-.. <br /> FEE <br /> -� ,FNFO �+ AMOUNT DUE AMOUNT REMITTEDEASHREGEIVEp BY DATE PERMIT•NO.',32.,HEV.I,IIJI i � «' '00 <br />