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� .. =r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL OC�gTON� CATH I <br /> SION <br /> P O BOX 295201 �� ✓ "'� <br /> (2Q9)S468-3447 <br /> Y <br /> /(Complete is Triplicate} <br /> 7 for a permit to construct and/or install <br /> tthe <br /> he Aulek rein�deationa�fr�ana <br /> Application is hereby �e•to liance rith Saqu a C1oatyin C ty ordinance No 9'and 1862 rd <br /> application is made in coin �r " <br /> JaaQ .in County Public Health services., � Lot Size/Acreage <br /> City ' <br /> Job Addrass� f11 011,0,11 11, 11 0 1111,111 <br /> Phone <br /> y� ddress ` <br /> Owner's Nam s� Phone9 <br /> License N <br /> Addres <br /> Contract WELL RE LACEMENT n T <br /> NEW WELL 0 OTHER IX pyp <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PopINES <br /> PUMP INSTALLATION Q ,� <br /> DISPOSAL FLD. P- fl <br /> SEWER LINES ---�-- <br /> DISTANCE TO NEAREST: SEPTIC TANK �----- AGRICULTURE WELL OTHER WELL fs �� <br /> FOUNDATION _��� <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFiCAT10NS „g , yyeH-Ctising <br /> ❑ Open Bottom 0 Manteca Die. of Well Excavation �er4ieetion <br /> n industrial 0 Tracy Type of Casing <br /> -------­— <br /> CJ Domestic/Private ❑ Gravel Pack Q �L <br /> I 1 Other ❑ Delta Depth of Grout Seal <br /> i M Public Surface Seal Installed by <br /> CJ Irrigation �" Approx. Depth ❑ Eastern State Work Done I <br /> F H.P. <br /> ` <br /> Repel Work Done L3 Type of Pump �--- Sealing Material A Depth �c <br /> Well Destruction O Well Diameter Filler Material 6 Depth' <br /> I Depth permitted if public sewer is <br /> TYPE OF SEPTIC WORK: NEW'INSTALLATION CI -.REPAiR1ADDITION L1 DESTRUCTION GI availablewithin200 feet.) <br /> Installation will terve: Residence Commercial Other <br /> II Number of bedrooms.� <br /> 1 <br /> Number o} living units: Water table depth <br /> Character of soil to a depth of 3 feel: Capacity—.— No. Compartments <br /> SEPTIC TANK. ❑ :Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT.Cl <br /> Distance to nearest: Wall <br /> Foundation r— Property Line -- ` <br /> Total length/sire <br /> LEACHING LINE ❑ .No. & Length of lines Property Line <br /> FILTER BED <br /> nDistance to nearest: Well Foundation P Y <br /> l 1 Depth Size Number <br /> SEEPAGE PITS Property Line <br /> SUMPS Ll Distance to nearest: Well Foundation�-- <br /> ' DISPOSAL PONDS <br /> ill be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the work w <br /> rules and regulations of the San Joaquin County <br /> fallowing: "l certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the <br /> employ any certifies the following;lowinga9c errtify that in thnner as 10 e performance of the work ecome subject to aforswh chompethis permit is issued, I ation laws of shall employ personsrsub ecrt to workman'scompensa- <br /> tion laws of California." <br /> The applicant a call for required inspections. Complete drawing on reverse side. <br /> Title: <br /> ��G� C � AGOG Date: <br /> s <br /> Signed <br /> OR EPARTMENT USE ONLY. Q (` <br /> Area <br /> Date <br /> Application Accepted byDate o <br /> e �— <br /> Pit or Grout Inspection by Data final tnspec ion by <br /> f 1 <br /> Additional Comments: <br /> Applicant - Return allCopiesto: SAN JOAQUIN C TY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> ok 445 N SAN JOAQUIN, P 0 BOX 2009, STOCKTON, CA 95201 <br /> CK <br /> FEE AMOUNT DUE AMOURECEIVED BY DATE PERMIT'NO. <br /> NT tiEMITTED CASH <br /> INFO � (_ <br /> . EH I3-214 IRev.r/A 51 '"l too <br /> EH 74.1e <br />