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APPLICATION FOR U11 <br /> ` <br /> SAN -PVAQUIN COUNTY PUBLICICESENVIRONMENTAL HEALTHn445 N SAN JOAQUIN, PHONE59 M20(�J1P O BO% 2009, STOCKTONP IT MIRES 1 FRPY C <br /> O <br /> (Complete in TriplicZ1., � <br /> Application is hereby made to San Joaquin County for a permit to construct 1v <br /> s <br /> application is made in ceniliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> I Job Addresa_�� City tit. i Lot Site/Acreage y <br /> Owner's Name 7 [L �g �I.� r„ <br /> Address ._-- Phone <br /> Contract fvAddress. C7lG,/_ � � <br /> License No Phone r(i3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> •INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ficatians <br /> i'1 Public 11 Other n Delta Depth of Grout Seal Vol Grout <br /> I I Irrigation —.Approx. Depth l I Eastern Surface Seal lnstallsd by <br /> Repair Work Done U Type.of Pump H.P. State vNARpr0 8- <br /> Well Destruction ❑ Wall Diameter Sealing Material i Depth S" <br /> Depth Filler Material i Depth SAN 30AQ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I AIRIADDITION DESTRUC t>4" N public sewer is {iV <br /> available within 200 feet:l <br /> Installation will serve: Residence Zcommerrial the( <br /> Number of living units:�_ Number of bedrooms ( I <br /> Character of soil to a depth of 3 feet: Water able depth �- <br /> SEPTIC TANK ❑ Type/Mfg I f'L Capacity No. Compartments d <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE No. & Length of lines — 0 Tota! length/size Q X <br /> FILTER SED /❑ DistarwA to nearest. Well 71- Foundation_ / Property Line <br /> i <br /> SEEPAGE PITS Depth Sire Number <br /> SUMPS ll Distance to nearest; Well An 0/ Foundation_J0 f Property Line <br /> r DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> ruler.and regulations of the San Joaquin County i <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 subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the pertormance of the work for which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion lava of California." 4 <br /> The applicant mus call for all tions. Complete"drawing on reverse side. <br /> Signed Title- <br /> Date, <br /> ` Date: 1 <br /> FOR DEPARTMENT USE ONLY p <br /> Application Accepted by -3 Area <br /> Pit or Grout Inspection by Date Final Inspection by to <br /> Additional Comments: <br /> Applicant - Return all,'coples to: San Joaquin County Public Health Services . <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE <br /> I <br /> 'L l� INFO AMOUNT'DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMlT'ND. <br /> « EM 134 tREV.tih51 1 F f l (j 210qq <br /> qi)�ais xe 1 l t `1 o(7 Ll <br />