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'I <br /> APPLICATION FOR PERMIT <br /> SAN­JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P Q BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> PERMIT =I_R0 1R10M DATE 10119P PL <br /> (Complete in Triplicate) <br /> Applicationie t,ereby made%to San Joaquin County for a permit to construct and/or install or �e i e This <br /> application Se made%in compliance vith San Joaquin County Ordinance No. III and 1862 and t Rule fancy 10 of San <br /> Joaquin County Public Health Services. <br /> 0 T f H1C� T City es^' Lot Size/Acreage �! <br /> Job Address <br /> pwner'S NameRR[ rn !�� I1cn Address Phone <br /> CanlractoffEIL61- -SS ?Ltfh1 S P Address36-3 4)J_1f1C_0JtJ L4icense No. o(072-- Phone 1 d 12 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service W.-11 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitor JngQ W!11 L� <br /> DISTANCE TO NEAREST:" SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE '7 <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> Fri , <br /> II INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I .i <br /> M Industrial en Bottom D Manteca Die, of Well Excavation / Dia. of Well Casing <br /> jo <br /> U Domestic/Private 0 Gravel Pack C3 Tracy Type of Casing Specifications <br /> M Public (_.1 Other 0 Delta Depth of Grout Seal { Type of Gr out <br /> Irrivation ` 0i _.:.Approx, Depth D Eas4r fq Surface Seal Installed by <br /> Repair Work Done ❑' Type of Pump Sudo H.� State Work Done <br /> Well Destruction O' Well Diameter �rf seall�terlal k Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTA CATION fl REPAIRlAODITION Cl .DESTRU 710N.CI {Na septic system permitted if public 561A Eir is <br /> l I available within 200 feet.)- <br /> I <br /> installation will serve:, Residence.�;.. Commercial_.__, Other <br /> ' Number ofliving units, Numbe of bedrooms <br /> Charactsi of soil to a'depth of 3 feet: Water table depth <br /> SEPTIC TANK C3 Type/Mfg Capacity No. Compartments. <br /> PKG. TREATMENT PLT. 0 1 Method of Disposal <br /> 11 Distance to Barest: I 1 Foundation Property Line r <br /> { <br /> LEACHING LIN_ E C1 No. & Lengt of lines Total length/size ' <br /> "FILTER BED ``i° Distance 10 crest: Well , oun tig Property Line <br /> SEEPAGE PITS I I be Size Number <br /> SUMPS -I LI Dista qce,It rest: Well,-- oun stio rope Line ^� <br /> DISPOSAL PONDS ❑ tl �"' -�.• 1 <br /> 1-hereby Certify that I have prepared this app Ication and that the work will be done in acc rdanc with San Joaquin c u, t inancTcomonse- <br /> . <br /> n of.lhe`San <br /> I;Ome owner or licensed agent's signature certifies following: "I certify that in the performance of the work for which this permit i <br /> employ any person in Such manner as to botorne,sublect to workman's compensation laws of California." Contractor's hiring of sub-c <br /> esrtifies the following: "I certify that in the perforfh ncsbf the work for which this permit is issued, t shall employ persons subject to wolion laws of Californie.r.., ! 6The applicant mus ca11f quired inspections. Complete drawing on reverse side. <br /> Signed �. Title: __��, � - Data: <br /> I{ <br /> .OR DEPARTMENT USE ONLY <br /> . <br /> iE# dl q <br /> Application Accepted by a. toAr.enc�eW.. Date Area <br /> Pit orou Inspection 1by " Date Final Inspection by a <br /> 4. <br /> Additionel Comments: <br /> Applicant — Return e31 copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVFSFON PERlfIT/SEttVICES <br /> 3 445 N SAN JOAQUIN, P 0 BOR 2009, STOCKTON, CA 95201 <br /> FEEINFO CASH <br /> AMOUNT DUE AMOUNT REMITTED ASH CK f RECEIVED BY DATE PERMIT NO. <br /> . EH 13•ze rRfV,analq�� 1 <br />