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APPLICATION FOR PERMIT <br /> A'b SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIAONMBNTAL HTsALTS DIVISION <br /> P 0 BOB 2009s, ST CKTON tr CA 95201 <br /> (209) 468-5447 <br /> PIMMIT ZIRHS_? s>I PROM: DATE I%% <br /> (Complete In Triplicate) <br /> Application is hereby sa►de,to San Joaquin County for a permit to construct and/or'install the work herein described. This <br /> application is made In caWlisne+ vIAWSan Joftuln,County Ordinance No. Sand 1$62 and the Rules and Ron <br /> egulatis of San <br /> Joaquin Coanty Public Health Services. <br /> Job Address `�-�`� • u. Cit Lot Size/Acreage <br /> Owner's <br /> Address Phone ~. <br /> • Contras <br /> fumtogu" Address 1Q License No '3 <br /> TYPE F WELL/PUMP; NEW WELL O WELL REPLACEMENT 0 DESTRUCTION.V of Service Nell <br /> PUMP INSTALLATION O SYSTEM REPAIR p OTHER O Monitoring Well n <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. - - PROP, LINE _ <br /> FOUNDATION AGRICULTURE WELL __�._...`. OTHER WELL - PITS/SUMPS:-:..T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom 0 Msnteca` Dia, of Well Excavation ., aim. of Wes Casing <br /> U Domestic/Private O Gravel Pack O Tracy Type of Casing Specificetione <br /> M Pugs Cl Other O Delta Depth of Grout Seal Type of Grout <br /> Cl Irrigation __ Approxi Depth O Eastern Surface Seat Installed by <br /> Repair Work Done U Type of Pump H.P. toD <br /> Well Destruction O Wen Diameter Sealing Material ii - 24W= <br /> Depth hiller Material i <br /> Depth 4- <br /> - <br /> TY E OF SEPTIC WORK: NEW,ROTALLATION JO REPAIRIADOITION cl DESTRUCTION O INo septic:agatem permitted N public sewer is <br /> availa it wttturt 700 feet.) <br /> Installation will serve: Residence— Commercial— Other _ <br /> Number of Evhv units: Number of bedrooms <br /> Character of son to a depth of 3 fat: Water table depth. <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.0 ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE L1 No.it Length of lines Total length/, <br /> FILTER BED O Distance to nearest: Wall Foundation Property <br /> w:. <br /> SEEPAGE PITS I I Depth Sie Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O _ <br /> I hereby certify that l haw 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 ) j <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work.for wh1ch, his permit is issued, I shah not <br /> employ any parson in such manner as to become subject to workman's compensation laws of California."ContractoK8446 or sutt•cor►trst ting signature <br /> cenifin the f Ing:"1 sonify that in the podorrrapce of the rk for which thispermitis issued,I shall employ personssubject to workman's compensa• <br /> tion laws of ,• <br /> The at cell for uif t' C drawing on rso side. <br /> Signed Tide: ^'.S.■� ._. pats: <br /> / �IAs'0 FOR DEPARTMENT USE ONLY rr}� <br /> �i <br /> Application Accepted by Date <br /> t <br /> Pit or Grout Inepe by Date Final Inspection by Date. _ <br /> Additional C n . , <br /> Applicant - all copies to, SAN JOAQUIN, COUFff fuslac HBALTH $i ucicB /[ <br /> SNVIRONMBNTAL HBAtTH DIVISION P=MIT/SSRVICX8 <br /> r 4+46 N SAN JOAQUIN, P O BOX 2009, ==TOM,, CA 94201 �✓ <br /> FEE AMOUNT 011E AMOUNT REMITTED CK 8 ASN RECEIVED BY DATE MIT'NO. ✓ <br /> INFO <br /> . EM 14.21111tY.i�w6! 1 �d --' MC <br /> EN;42a v . <br />