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APPLICATIONFOR PRRHIT -- - <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES {� <br /> _ - <br /> S� <br /> ENVIRONYENTAL HEALTH DIVISION D <br /> 445 N SAN JQAQi3IN, PHONE (209)468-3 <br /> P O BOX 2009, STOCKTON, CA 9520Y <br /> PE T R S 1 Y PRY E msd <br /> G- � �� -C V, (Complete in Triplicate) , �f tt <br /> truct an von ere n eacri This <br /> Application is hereby made to Sao Joaquin County for a permit to cons ,_s �8 Aegu]at.ione of Sart, <br /> �i applieatioa Is made in caWliance with San Joaquin County Ordinance 11o. 51+4 and 1862 artd � <br /> 3oequin county Public Health Services. O'er 7 <br /> City c.-- Lot Size/Acrre$e <br /> Job Address / <br /> Owner's Name <br /> -� Address �0 f Phone <br /> c y <br /> } Contractor Address _ _ <br /> .. �1 License N� -Phone <br /> i TYPE Of WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT C� DESTAUCT40N Cl out of Service Well C1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR <br /> OTHER 0 I+lonitoring Well In <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> PROP. LINE <br /> +I{ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> 11 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> Cl Industrial 0 Open Bottom O Manteca Dia. of Well Excavation 5pectl+catlons <br /> I`1 Domasticiprivate ❑Gravel Pack 0 Tracy Type of Casing_. <br /> i'I Public <br /> Cl,Other fl Delta Depth of Grout Seal Type of Grout._ <br /> *Irrwlion Approx. Depth t Eastern Su ace Soul Installed by <br /> fi,P. State WOflt Dat F <br /> Repair Work Done Type of Pump ( 3ealittg Itaterial i Depth <br /> Wal#Destruction ❑ Well Diameter <br /> Tiller Material i Depth <br /> Depth <br /> �TYPE Of SEPTIC WORK: NEW INSTALLATION t 1 REPAlAiADDITION I 1 DESTRUCTION I I (No septic sy:tem permitted it public sewer is <br /> available within 206 feet,I <br /> Installation Wig adrwe: Residence — Commercial_ Other S. � <br /> Number of living units: Number of bedrooms (� <br /> Character of soil to a depth of 3 feet: Watar table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal J <br /> "Distance to nearest: Wall Foundation Property Line <br /> II LEACHING LINE 171 '�No. 3 Length of linea Total length/size <br /> FILTER BED C1 i Distance to nearest; Well Foundsttpn Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Lfo Distance to nearest; Well Foundation Property tins <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, elate fawn, and <br /> } rules and regulations of the San Joaquin County <br /> "I certify that in the Performance of the work for Which this permit is issued, 1 shaft not <br /> }lorry owner or IiceneW agent's signature certifies the following: <br /> employ any parson in such manner as to become subAct to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifiaa the lotlowirlg: "I canny that in the Worrnarica Of the work fpr which this parmir is issued, I shall employ persona subject to worknnen'f nae• <br /> E tion laws of r"" <br /> Th plicant must ah for all troquir inspectiana. Complete drawing an se aide. <br /> y r —Title <br /> �raPs�d- <br /> 7 <br /> e: - <br /> FOR DEPARTMENT USE ONLY <br /> Appfieation Accepted by e` Rate <br /> Area <br /> * Date Firm Inspection by <br /> Pit or Grout Inspection by .,...b«-� . <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Servicee <br /> 445 R San Joaquin, P O Rox 2009, Sekn, CA 95201_ <br /> I � P RMIT'Np. <br /> FEE �,CNt)11N7 9tJE AT115T REMtrTEq CASH REGEtVE9 8Y• .--P GATE E <br /> i IkfO CASHI3,14InEY.$IA5i7� <br /> EH t�.2a <br /> k <br /> I L - <br />