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APPLICATION FOR T(m SAN JUAQUIN COUNTY PUBLIC Aii�$t01BBe <br /> ENVIRONIMTAL HEALTH 067 L� <br /> 445 N SAN JOAQUIN, PHONE S�� <br /> f P O BOX 2009, STOCKTON, <br /> r <br /> REMIT IRES FROI[ DX.LSS <br /> AT <br /> S <br /> (Complete in Tripli(Laiftv <br /> 1.1 ' <br /> Application to hereby Lands to Ban Joaquin County for a permit to construct and/or install the vork herein described. This <br /> Joaquin Con.is made in coeiliance:with Ban Joaquin County Ordinance No. 549 and 1$62 md the Rules and Regulations of San <br /> Joaquin Coaaty Public,Health Services <br /> Job Address �1 I �i Cir YJ <br /> db t /Af cte e <br /> Owner's Name Address <br /> Contras Address r - License No. L` Phone U <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well 0 <br /> PUMrINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well [3DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT <br /> 0 Industrial 10 Open Bottom ❑ Manteca Dia. of Well ExcavationI Rik <br /> �roCasing <br /> Well <br /> n Domestic/private ❑ Gravel Pack ❑ Tracy Type of Casing_ ff Well <br /> I') Public Ci Other fl pelta ations <br /> Depth of Grout Sealof Grout <br /> I 1 irrigation' Approx. Depth I I Easlem Surface Seal installed by <br /> Repair Work Done U ' Type of Pump 1 H.P. ` (1NT <br /> Well Destruction ❑ Weil Diameter. Sealing Material & Deptl&�n <br /> Depth I tier Material i Depth <br /> TYPE OF SEPTIC-WORK: NEW INSTAL TION I REPAIR/ DITION ESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.) `\ <br /> Installation will serve: A7, rwe Commercial OtherNumber of living units: - Number of <br /> Character of sod to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg t Capacity- No. C <br /> PKG. TREATMENT PLT.❑ Compartments <br /> Method of Disposal <br /> Distance to nearest, Well <br /> Foundation Property Line <br /> LEACHING LINE No. b Length of lines `�' <br /> Total length/size <br /> FILTER 8E0 p Distance to nearest: Well Foundation , <br /> Property Li <br /> /( <br /> SEEPAGE PITS Depth Si:e s77 <br /> - Number <br /> 15 <br /> SUMPS LI Distance to nearest; Well Foundation / <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, and <br /> rules and MCI of the San Joaquin county <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."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I'certify that in the Pet'lormancs of the work for which this permit is issued,i shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m an f all r ired ' ions. Complete drawing on reverse side. <br /> signed .9y <br /> Title: ,. <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> A cation Accepted by Date <br /> Area <br /> Grout Inspection by ate incl tnspectlon by Z Date <br /> Additional Comments: <br /> r <br /> Applicant - Return all eopies.to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services I <br /> 445 N San Joaquin ox.2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE IL AMOUNT REMITTED <br /> NFO r <br /> I �vt t K RECEIVED 8 DATE PERMI7'NO. <br /> • EH 5424(RLN.I/n s! <br /> EH t4.7e <br />