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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 202,ST 09) 8$3447 CA 95201 <br /> R <br /> (Complete fa Triplicate) <br /> for a permit to construct and/or install the work herein deleationsdof Sans <br /> Application is hereby msde,to San <br /> Joaquin countyfor <br /> County Ordinance No. 549 and 1862 and the Rules and Renu <br /> application is made in compliance with San Joaq . <br /> Joaquin County Public Health.services. Lot Site/Acresae <br /> Al � ; <br /> KJob Address , r U Phone <br /> miss <br /> ?D I o x + <br /> Owner's Name Phone <br /> one <br /> License No. ____------- <br /> Address. DESTRUCTION ❑ Out of Service We-11 ❑ <br /> k Contractor WELL REPLACEMENT - Monitoring Well <br /> NEW WELL 01 / <br /> TYPE Of WELL/PUMP: SYSTEM REPAI ❑ OTHER ❑ <br /> I PUMP INSTALLATIONOkSPOSAI❑ FLD,_ PROP, LINE <br /> DISTANCE: TO NEAREST: SEPTiC-TANK SEWER LI S pTHER VYELL�-- PITS/SUMPS .� <br /> AGRICULTU WELL_-. <br /> FOUNDATION ��-- TR TION SPECIFICATIONS <br /> k INTENDED USE TYPE OF WELL PROBLEM�^ AREA CO pis. of Well Casing (} <br /> ❑ Open Bottom © Manteca Die. o ell Excavation Specifications V <br /> n Industrial ❑ Tracy Type C ng <br /> U Domestic/Private C1 Gravel Pack Type of Grout <br /> Cl Other © AelI De h of Grou ea 771 <br /> C3 Public (I Seal Insta by <br /> =1IrnUation .•.--,Approx' Depth 0 Eastern State Work.Done — <br /> i. Repair Work Done LJ Type of Pump Seal ng Material a Depth <br /> I Well Destruction O Well Diameter <br /> Filler Mpth aterial = <br /> Depth <br /> available within 200 feet.l <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION J] REPAIRIADITIDN Cl DESTRUCTION i<l lNo septic system permitted if public sewer Is <br /> D <br /> installation will serve: Residence .G Commercial— Other <br /> Number of�living units: Number-of bedrooms _1.1___A Water table depth <br /> Character of soil to a depth of 3 feet: Capacity =--- No. Compartments <br /> l SEPTIC TANK: © Ty"Imfg �.; Method of Disposal <br /> PKG. TREATMENT PLT.❑ l Foun a ion — Pr a Line I <br /> Distance one est: <br /> w <br /> I <br /> Totallengthlsi=e <br /> LEACHING LINE ❑ No. & Length of lines Property Lina —� <br /> n Distance to nearest: Well_.�..-. foundation r �--- <br /> FILTER BED - <br /> Size Number <br /> SEEPAGE PITS I 1 Depth Property Line�----- <br /> SUMPS <br /> Ll Distance to nearest: Wall�.�– Foundation�.�.--- <br /> j DISPOSAL PONDS D <br /> t l horeby certify that E have prepared this application and that the work will be done kn accordance with San JoaQuin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County g „ <br /> t Home owner or sed agent's signature certifies the followin I certify than In the periormancs of the work for which this permit is issued, I signature <br /> shall not <br /> 5 of <br /> Wation <br /> any f Ilovr+ in such rna�lh�aln the perfoto rmance of wo kaforwh chehis pe m�Ws issued,fI shall employ peraonersubjecring t to arkman�aGompenta <br /> j certifies the g ' <br /> tion Iowa Df alkf nla <br /> The lawsapPla m 11 for all required Inspections. Complete drawing on reverse side. <br /> Date: <br /> Title: <br /> >(Signed <br /> EPARTMENT USE ONLY <br /> Date Ares <br /> Applicatio Accepted by �I <br /> 1---- <br /> DotsL��" <br /> pit or Grout Inspection by Date Final Inspection by <br /> Additlonal Comments: <br /> Applicant r Return all copies to: ERVICES <br /> ENNVIRONIMENTALOUNTY HEALTHUBLIC HEALTH DIVISION PEEWIT/SERVICES <br /> 448 N SAN JOAQU IN, P O BOX 2009, STOCKTON, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> r EH 13.24IREV.11A5) tD� �p� -COD <br /> {H:416 <br />