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APPLICATION FOR PERM I T 0�r"V <br /> SAN JOAQUIN COM" 'PUBLIC HEALTH V - . ' <br /> TNVIAL HEALTH DIVISI <br /> 445 N SAN JOAQUIN, PMM (209)46 <br /> P O BOX 2009, STOCKTON, CA 952AC <br /> �> <br /> (Complete in Triplicate) <br /> Anucation is hereby at de.to San Joaquin County for a permit to construct and/or insta . the work herein described. This <br /> spplicstica is nude in conollan" with San Joaquin County Ordinance leo. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> ` or ► Lot Size/Acreage eVcJob AddressCity st7-r-t <br /> Ownsrs <br /> Nara t�XaCs• `�" • Address C1-61,J 'CA sfS'24r- Zeit <br /> Phone <br /> Contracts W~ we_Address 14-.4 42-Ara QA MO!fZ License No. Z�L zoo Plwrrt�r <br /> TYPE OF WELL/PUMP: NEW WELL$. WELL REPLACEMENT M DESTRUCTION O Out of Service well <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Yell ]$ N <br /> DISTANCE TO-NEAREST: SEPTIC TANK P Sb r SEWER LINES > DISPOSAL FLO. PROP. LINE <br /> FOUNDATION r AGRICULTURE WELL tP�L_ OTHER WELL-> LIMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Indtaaial O Open Bottom O Manteca Dia. of Will Excavation of Weil Casing Z�� <br /> Ll OomesticiPrivate O Gr"Pack O Tracy Type of Casing Am Specifications -rZ4 40 <br /> 1'I Public 6�1-01hsr n Delta Depth of Grout Seal S Type of Groua.144L emit <br /> i I krigatiom aC.Approx. Depth I 1 Eastern Sursoe Seal Installed by t N+► w• t <br /> Repair Work Done U Type of Pump H.P. Stas Work Done.: V <br /> Wale Destruction O Well Diameter Sealing Material i Depth <br /> Depth Filler Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 fest.) <br /> Installation will serve: Residence_ Commercial.._ Other <br /> Number of IFring units• Number of bedrooms <br /> Character of sell to a depth of 3 fest: Water table depth <br /> SEPTIC TANK. O Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT.O Method of 0"'AF <br /> Distance to naareat: Well Foundation Property Line <br /> n r _1VFn <br /> LEACHING LINE O No. B Length of lines Total lengthl iza MARK, 15 IM <br /> FILTER SED Q Distance to nearest: WON Foundation Property Line <br /> SEEPAGE PITS 1 I Depth Site Number \ <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> OISPOSAL PONDS O <br /> I hereby aarti ly that 1 haw prepared this application snd that the work WON be done in accordance with San Joaquin county ordinances, stats laws, and <br /> rules and rsgtrlslioNs of the San Joaquin County <br /> Hone owner orNearesd apwlts asrtifisa the following: "i certify that in the performance of the work for which this permit is issued,I shall not <br /> ovk0 arty arson in such mewwas to=blloonns subject to workmen'*compensation laws of Califomfit."Contr~s hiring or sub-contrsetir 1 NOW— <br /> cartMiaathe feiowing:"I silly Mtat in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compsnM- <br /> don laws of Cawomis." <br /> The applicant t:a*for all required irupections. Complete drawing o'n/reverse side. <br /> siprnad x r c�.�.,C �: (,�.... sr Title:�S►�Cw e c.�.a rf7� oats: 3 •' yr 4 <br /> FOR DEPARTMENT USE ONLY (x� <br /> AOPCon Aeoepted by Date �� Area <br /> Pit or,Grout Inspection by /),—Dot* ✓ Dam <br /> FC <br /> Additonsl Comments: <br /> • �►1 <br /> Applicant - Return all copies to: San Joaquin County Public Health Se a �/Z.- <br /> ~: <br /> Reviromontai Health Perait/Servic <br /> 445 It San Joaquin, P O Box 2009, s, 95 <br /> In AMOUNT atm AMOUNT REMITTED CAH RECEIVED 0 ,! <br /> m*34IRev.I s, �` x(09co <br />