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V. <br /> APPLICATION FOR PSR1[I T <br /> SAN JOAQUIN COUNiWl <br /> TY PUBLIC <br /> ENVIRONMENTAL <br /> HEALTH SERVICES <br /> 445 N SAN 'STH DIVISION <br /> 'P O N, PHONE (209)468-2420 <br /> BOX 2000 9, STOCKTON, CA 9520 <br /> a <br /> ' ERid T IRE y <br /> (Com FR D TE <br /> APPlicatloa is here Plate In Triplicate) <br /> + application is.assde made to Ban Joaquin County for a <br /> Joaquin Count oi�,liaace vlth San J Permit to construct <br /> J Public 8ealth Services.- Quin County Ordinanceend/or inatnll the work herein described. T <br /> No. 5bq and 1862end the Rules and Aegulation. of Bans <br /> Job Address - �� <br /> 2 City <br /> Owner's Name' //, �! Lot Size/Acreage <br /> Address <br /> Contractor Phone <br /> TYPE OF WELL/PUMP: Address <br /> `NEW WELL p �— License No <br /> PUMP WELL REPLACEM Phone- < <br /> INSTALLATION ❑ _ ENT n , DESTRUCTION <br /> DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR C1 Out of Service ile1I 0 Y <br /> ---------.: SEWER LINES OTHER © Monitoring Well <br /> a <br /> fid{1NDATION � DISPOSAL FLD. <br /> Fi' <br /> INTENDED USE �� AGRICULTURE WELL -- PROP. LINE <br /> TYPE OF-WELL �--- OTHER WELL `�" <br /> L� Industria! O PRQBL EA CONSTRU P[TS/SUMPS <br /> Open Bot CTION <br /> 1.1 DomesticlPrivate , tom ❑ Manteca SPECIFICATIONS <br /> C1 Gravel Pack ❑ Trac D18' of Wall Excavation <br /> F I I,Publrc Y Type of Casing_ D� of WON Casing . <br /> I 1 Irrigation [] 011ier fl Delta <br /> y Depth of Grout Seal Specifications <br /> Repair Work Done 0 Type of PurnpDepth I I Eastern Type of Grout ' <br /> Surface Saul Installed by <br /> WOO Destruction p Well,Diameter H.P. <br /> f *z �` 3ea11ag lfsteriel E, State Work Done <br /> Depth Depth <br /> TYPE OF'SEPTIC WORK: T11ler Material i De- <br /> NEW INSTALLATION pth. <br /> REPAIR/ADDITION I t DESTRUCTION i t INo $eptic system W <br /> F - Installation veil! serve; 1 <br /> Residence_� Comr►tercie!Zavailable within permitted if public Q � <br /> Numbir Of livin Other�� r�S 2pp feet. <br /> P sewer is <br /> living.units: Number of (1 <br /> Character of eo'to a de bedrooms <br /> FSEPTIC TANK Pth of 3 feat: i <br /> PKG. TREATMENT PLT.p Typ��lutffl Water table depth <br /> i Capacity <br /> No. <br /> Distance to nearest: Compartments <br /> Well- � �� <br /> Foundation Method of Disposal <br /> LEACHING LINE Property LinoV'� ; <br /> FILTER bEp NO- & Length of lines <br /> �I Distance to ; <br /> nearestWali trc. Total length/site <br /> �'�- Foundation <br /> SEEPAGE PITS <br /> ! I Depth . ----- ., Property Line <br /> SUMPS ^ <br /> L] Distance to. Number <br /> DISPOSAL PONDS nearest: Wel! . <br /> 0 -� Foundation <br /> !hereby certify that I have -"�-�-- Property Line ` <br /> prepared this application and that the work will be dans in accordance with San Jo j <br /> rules and regulations of the Sen Jon <br /> Home owner o►licensed 4uin county <br /> employ an agent's signature certifies the fallowin aqutn county ordinances, :lata laws, and <br /> fpersontn such <br /> manner as to oma g: 'l certify that in the <br /> certifies t Mowing:,q an! than in theme subject to workmen's corn performance of the <br /> tion laver of Calif performance of the work for which n3ation la irk for which this permit is issued, I shall not <br /> orn[a." laws of California."Contractor's hiring <br /> The applicant',must call for r this Permit is isaued,!shall employg or sub-contracting signature . <br /> aqu'red'ins Persons subject to workman's cornQen�• j <br /> Signed pectionr. Complete drawing on r arae <br /> f Title- <br /> Date: <br /> FOR DEPARTMENT USE ONLY ��l <br /> Appficatksn Accepted by. i <br /> P. G�prtt! t by 3 Due 1 A Y <br /> Y} Date �(0 rea <br />`Additbnaf Corti Final Inspection by <br /> Comments. <br /> hPPlican Return alt copies to: San Jos u 'flty Data 1� <br /> f Hnvironmental Health relic Health Services 7 <br /> 445 N San <br /> Joaquin. rmit/Services <br /> FEE q P O Box 2048, Stkn, <br /> INFO AMOUNT DUE CA 35201 <br /> AMOUNT REMIT <br /> TED K ' <br /> 7�i 111EV-�resr CASH RECEIVED BY <br /> t•% •17(7 r O D DATE PER <br /> MIT"NO, <br />