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f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL ILEALTH DIVISION <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> Frit l .T REe ]_ YEAR F`ROH DATE I SSUXD <br /> (COmplete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to const`ruot and/or install the work herein described. This <br /> application Is made in ocupliance with San Joaquin County ordinance-No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I�y <br /> Job Address . .S City ?&kkll Lot Size/Acreage 20 <br /> Owner's Name ddress Phone ^ <br /> Contracts4/e� Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 Out of Service Well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ER 0 Monitoring Well �� <br /> DISTANCE TO NEAREST: TANK SEWER LINES D1SP LD. PROP. LINE <br /> FOUNDATi AGRICULTURE WELL THER WELL PITS/SUMPS ..� <br /> INTENDED USE TYPE OF WELL PRO SEA CO CTION SPECIFICATIONS- - r r y k <br /> f.1 Industrial ❑ Open Bottom 0 Manteca _ ia.J of Well Excavation Dia, of Well Casing Ll.-- <br /> U Domestic/Private 0 Gravel Pack ❑ Tr Type sing Specifications <br /> L7 Public f l Other Delta Depth of Grout I Type of Grout <br /> CJ IrriOation __.Appro epth 0 Eastern Surface Sea) installiid b <br /> Repair Work Done U Typo ump H.P. State Wo ne _ <br /> Wall Destruction O Wail Diameter Sealing Material i Depth <br /> Depth Filler Material i Depth ' <br /> F TYPE OF SEPTIC WORK; NEW INSTALLATION.0 REPAIR/ADDITION L DESTRUCTION F o septic system.permitted if public sewer is T� <br /> ., vailable within 200 feet.! <br /> installation will serve: Residence_.._ Commercial---:- Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet. +Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ��_ No. CompartmentsPKG.,TREATMENT PLT. C1jp I <br /> Method of Disposal <br /> Distance to nearest: Well _ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/sire <br /> t FILTER BED C1 Distance to nearest: Well Foundation Property Lina <br /> SEEPAGE PITS I. 1 Depth Siza Number <br /> SUMPS Ll Distance to nearest: Wall Foundation Property Line r <br /> r DISPOSAL PONDS 0 if <br /> .,I hereby certify that I have prepared this application and that the work will be done in accordance with San.Joaquin county ordinances, f <br /> rules and regulations of the San Joaquin County , state taws, and" <br /> +tome owner Or licensed agent's signature certifies the followin I certify that in the dr <br /> employ an 9' � performance of the work for which this permit is issued, I shelf not <br /> A Y y person insuchmanner as to become subject to workman's compensation laws of California." Contractor's hiring of 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 persona subject to workman's compenaa <br /> tion laws of California." <br /> The applicant m i call for all'required ins ,Etions. Complete drawing on reverse side. <br /> ,JeSigned Title: <br /> Date: <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by ----_ <br /> at <br /> Da �� <br /> _._ Araa <br /> Pit or Grout Inspection by Date _ Final Inspection b ! I <br /> Date <br /> Additional Comments: <br /> Applicagt - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> FEEAMOUNT DUE ATMMINT REMITTED CK <br /> INFO CASH RECEIVED BY DATEPERMIT'NO. <br /> EH13Y4iREV.i/is Ll <br /> LqLloo <br />