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KVO APPLICATION FOR PERIL I T <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> RIMILWIRIES R PROM DAIE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby alade'to San Joaquin'County for a permit to construct and/or Install the work herein described. This <br /> application is made in cons liance with San Joaquin County Ordinanc Hfl. 49 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> {' <br /> Job Address .� II /V / City Lot Size/Acreage <br /> 9 <br /> Owner's Name Address r W4 <br /> Phone <br /> r/ w5 t <br /> Contractor dress License No. I Phone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT 0 DESTRUCTIO t of Service Well L1 <br /> PUMP�INSTALLATION C3 SYSTEM REPAIR C1 OTHER p Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C <br /> M Industrial ❑ Optin Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f <br /> U Domestic/Private Cl G►avef Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public i"1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> CJ Irrigation �..+Ox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H,P, State Work Oona <br /> Well Destruction A_ Well Diameter J� Sealing Material i Depth / <br /> Depth 0' l Filler Material i Depth AP-7 j <br /> TYPE OF SEPTIC WORK: NEW,INSTALLATION❑ 14EPAIR/ADDITION M DESTRUCTION ❑ (No septic system permitted if 1blic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residen Ile.,..,� Commercial,.,_ Other 16- <br /> Number of living units: INumber of bedrooms Lli 21 ' <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Typo/Mfg Capacity No, Compartments <br /> PKG. TREATMENT PLT, ❑ Method of Disposal �la� <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING UNE ❑ No. .6 Length of lines Total length/size ` S <br /> FILTER BED n Distalnce to nearest: Well FoundationProty Line \�l <br /> fM perv <br /> SEEPAGE PITS It Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ II, <br /> 9 <br /> f hereby certify that I have prepare 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 /> +come owner or licensed agent's si4kature cenifies 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 r u��edt' s amplete drawing on raver si <br /> Signed II Date: �® d <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by II Date Area <br /> Pit or Grout Inspection y �! Date Final Inspection by Data fills <br /> d� <br /> Additional Comments: <br /> Applicant - Returnall c to: S JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> IIS ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> I 445 N SAN JOAQUIN, P O BOX 2008, STOCKTON, CA 98241 <br /> FEE <br /> INFO AMOUNT D�`E AMOUNT REMITTED CK <br /> JJ r CASH RECEIVED 8Y DATE PERMIT'NO. <br />. EH 1J•241JIEV iiMs� 1-,D �I <br /> EH 14•26 <br />