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APPLICATION FOR PERMIT <br /> �... > SAN JOAQUIN-COUNTY PUBLIC HEALTH SSRVICEB <br /> i ENVIRONMENTAL`,HBALTH DIVISION <br /> i P O BOX 20698TOCKTON, CA 95201 <br /> ° r (209) 468-3447 <br /> R - <br /> F (Complete in Triplicate) <br /> Applicatfoa 1s hereby made to San Joaquin County for a permit to construct and/or install the ►cork herein described. Thie <br /> application fe tendo in e4th Seryance vith San Joaquin County Ordinance No. 549 and 1862 end the Rules and Regulations of San <br /> Joaquin County Public Heiith cervices. - <br /> Job Address —7 <br /> Cityle-L� <br /> Lot 'i ze/Acreage <br /> I Owner's Name �ITss / // • ,oO�CA- 9S 2O <br /> Phone <br /> Contractor e <br /> Address License No. 6Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service We11 ❑ _ <br /> PUMP INSTALLATION CI)� SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK [� <br /> SEWER LINES -----�- DISPOSAL FLO. PROP. LINE <br /> FOUNDATION _ __ AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 1!►Zn Ind strias ❑ Open Bottom —M j <br /> �_ ❑ Manteca Dia, of Well Excavation <br /> sstic/Private ❑ Gravef Pack _ ❑ Trac �.. Dia, of Well Casing <br /> M Public 1:1 OT'ier i Y ,TYpe of Casing <br /> D Delta Specifications <br /> M hrigation - '4 Depth of Grout Seat ' <br /> —.Approx. Depth ❑ Eastern Type of Grout <br /> Repair Work Done U T p Surface Seal Installed by <br /> Well Destruction Type of Pum ' 1 H p t State Work Done 1 <br /> O Wait Diameter �.�r Healing Xsierial i Depth <br /> Depth <br /> 'Piller Material i Depth ` <br /> TYPE OF SEPTIC WORK: fVEW.INSTALLATION 1L REPAIR/ADDITION C7 DESTRl1CTION Ci INp'seprii:_system permitted if public sewer is <br /> r � <br /> Installation will serve: Resident a Comm_ar e1� "'^--- �—M �_�. T -"�available.within 200 feet.►. <br /> one►' <br /> Number of living units: i?z Number of`'bodroonis <br /> Character of agil to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ ! Ca city, No. Compartments <br /> DiMethod of Di <br /> Div to nearest; F undation� Disposal <br /> u r`t % Property Line ` <br /> LEACHING LINE ❑ No. & Length of lines s <br /> FILTER BED f I Distaince to nearest: W Total length/sire <br /> Foundation � Property Line _ <br /> SEEPAGE PITS 11 Depth <br /> SUMPS Sire_ { Number <br /> LI Distance to nearest: Well„ _ <br /> DISPOSAL PONDS Foundation Property Line <br /> --I-hereby-certify that f have-prepared this appiication,and.that the-work will be done in accordance with San Joaquin county ordinances, state law <br /> rules and regulations of the San Joaquin County { <br /> Home owner or licensed agent's signature certifies the followinV. theg; s, and I <br /> employ any per wch manner Mks to become subject to workman's aampenaat on laws of California:" Contractor's hiring or sub contracting signature { <br /> Performance of the work for which this permit is issued, I shall not <br /> certifies the lowing; 'I certify that`n the perfor ca Of the work for which this permit is issued, I shall employ tion laws Cali}orals y p y persons subject to workman's compensa- <br /> The appG ant m s for allc ' <br /> S. Com le ►awing on r side: �� /4( Ah? <br /> a/ <br /> Signed <br /> Title: i <br /> Date: <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by t <br /> Date Area <br /> Pit or Grout Inspection by �I J <br /> Date Final Inspection by <br /> Additional Comments: I� Data <br /> Appllcaat - Return all copies to: <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SRRVICgS <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009 t3 <br /> , TOCKTON, CA 98201 ��vl° <br /> INFO AMOUNT DUEL AMOUNT REMITTED CK <br /> EN 0-24 IREV. <br /> CASH RECEIVED BY DATE <br /> ,1 � PERM17 NO. �(�J <br /> r i w Sr ��� <br /> EH;x•26 !` l�3 I tJ <br /> II <br />