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'� I <br /> APPLICATION FOR PERMIT j <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION ; <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> BERM T EXPIRES-_1 XEAR FROM UTIUSSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in ccrapliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. p <br /> Job Address , //J <br /> l J� _ Cityot Size/Acreage r <br /> Address - _ Phone <br /> Owner's Name G� e + <br /> \ <br /> _?t Phone ` <br /> Contractor � SAddress 0 License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑* WELL REPLACEMENT.0 DESTRUCTION Out Of Service Well <br /> —% Monitoring Well <br /> PUMP INSTALLATION 0 SYSTEM! R <br /> TI ., SYSTEM C7�"°•.�,�` 4. OTHER O <br /> II _ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ��- � DISPOSAL FLO. t' PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> • Dia. of Well Casing <br /> 0 Industrisi 0-0-9-on '© Manteca "13ia. of Weil'Excavation =~"� f1 <br /> U Domestic/Private 0 Gravel Pack 0 Trace„___--Ta Casing Specifications <br /> M Public' 1:1 OtherDepth of Grout Seal Type of Grout_ <br /> G Irritation ._.._ Appr�.*Depth D Eastern Surface Seal Installed by f� �� <br /> L3 T offPum N-P. State Work Done_. circ iF. <br /> Repair Work Pon! Type p <br /> Ree -=- <br /> p r - <br /> Sealing Material i Dept <br /> Welk Destruct' n WeII�Diameter Filler Material i Depth <br /> �f3epth •✓�/// `tel <br /> YPE OF.SEPTIC WORK: fVEW INSTALLATION 10 REPAIR/ADDITION 71 DESTRUCTION CI (No septic system permitted,if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial_ Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3,feet: Water table depth f <br /> SEPTIC TANK O Type/Mfg Capacity' No. Compartment's �_._ <br /> -PKG. TREATMENT PLT. C1 Method of pittpoaal <br /> It Distance to nearest: Well Foundation r Property Line f. <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number \ <br /> SUMPS LI Distance to nearest: Well foundation_. Property Line \ <br /> DISPOSAL PONDS 0 <br /> 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 /> 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 sutilect to workman's c0mpensatwn laws of California." Contractor's hiring or sub convecting 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 /> t The applicsn s all 10-11AWequir s Complete drawing on reverse tide, <br /> Signed ills: <br /> Date: Zak <br /> OR DEPARTMENT USE ONLY/ <br /> Application Accepted by a4AA& Date, `�"�4_ 4 Area <br /> Pit or Grout inspection by Date ''�- Final Inspection by Date <br /> Additional Comments: <br /> + Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> EN.V.IR0NMEN-'PAL-REALT-H.-DI-V-144DN-PERYi-T/'SERVICES �(rX <br /> 445 N SAN JOAQUIN, P 0 BOX 2008, STOCKTON, CA 85201 \\J� <br /> FEE AMOUNT RUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITFNO,INFOEHlS•NIREV. /RSI9 � <br /> # EFi'^.�36 .. <br />