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3 6 <br /> APPLICATION FOR PERMIT <br /> 'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 P�OHAZELTON BOX 2009E,vSTOCKTON7 CA95201 <br /> I� f <br /> II XPRES 1YERFRMDT <br /> ID <br /> I� (Complete in Triplicate) <br /> hereby made to San Joaquin County fora permit to construct and/or install and thee vork Rules andein Regulationsdof Sans <br /> Application is her y <br /> application is made incompliance vith San Joaquin County Ordinance No. 5w9 and 1 <br /> Joaquin County Public Health Services. <br /> city • Size/Acreage <br /> Job Address D <br /> Phone <br /> es _ <br /> Owner's Name <br /> `s No. Phone 6 <br /> ,r s <br /> Contractor DESTRUCTIO Out of Service Well <br /> NEW WELL ❑ WELL REPLACEIVIEN7 Ci Monitoring Well [I <br /> l TYPE OF WELL PUMP. SYSTEM REPAIR 0 OTHER C3PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE 70 NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> I <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA Dia. of Well <br /> CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> C] Industrial Q..Open Bottom 0 Manteca t Type <br /> of Well Excavation Specifications <br /> ,Type of casing <br /> D Domestic/Private ❑ Gravel Pack ❑ Tracy Depth at Grout Seal Type of Grout <br /> i'l Public d:1 Other fl Delta <br /> f,• -" <br /> ' I I irrigation 1 {^App ox, Depth l I Eastern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done LJ Type of Pump Sealing Material & A th <br /> Well Destruction O Well Dia4sler <br /> i <br /> Depth i3 Filler Material pth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlAODITION DESTRUCTION availablelIf public sewer is <br /> within 200 feet.) <br /> Installation will serve: Residence'° Commercial___ Other - b <br /> Number of living units: Number of bedrooms <br /> ater table depth <br /> Character of soil to a depth of 3 feet: X0. Compartments <br /> SEPTIC TANK D Type/M0 Capacity <br /> PKC. TREATMENT PLT. C7 ` _/ �y, Metfiad of f is sal <br /> s € Distance to nearest: Well Foundation tl - Property Line n <br /> LEACHING LINE ❑ No. &'Length of lines ,Total length/size <br /> iProperty Line <br /> FILTER BED [-J Distance to nearest:- Well��ry Foundation ; <br /> rr <br /> i <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> k <br /> I� <br /> DISPOSAL PONDS C1y <br /> t5 I hereby certify that I have prepared 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 r <br /> k 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 /> 4 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 /> I certifies the following: "I comity 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 us r aN r uired ' sp ctions. Comple drawing an reverse side. <br /> i Title: - Date: <br /> Signed <br /> I 'I FOR DEPARTMENT USE ONLY <br /> l Ao--ri 1 Area <br /> Application Accepted by i. Date <br /> Pit or.Grout Inspection by �r Date Final Inspection by I^, ate <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> hServices, Environmental- Health Permit/Services <br /> II 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE _ CK RECEIVED BY DATE PERMIT NO. <br /> , IN��//F//O� AMOUNT DUE AMOUNT REMITTED CASH <br /> . EN 13•241REV.I�n51 SY\ `l <br /> l EM 14-26 �. <br />