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1 <br /> t; <br /> APPLICATION r <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j <br /> ENVIRONMENTAL HEALTH DIVISION { <br /> 445 N SAN -JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCRTON, CA 95201 <br /> RM I MIRES 1 -YEAR FR9M DATE <br /> -A .._, ?..-:ra,:;« , ,.•y. _ (Complete- in Triplicate) <br /> Application-in hereby made.to San Joaquin County for .& permit,to toitatruct and/or install the nark herein described. This <br /> application is made in cotapliance xith San Joaquin County Ordinance No. 549 and 1862 And the Rules and Regulations of San <br /> Joaquin County Public Health Sarvieee. <br /> Job Address., sq '�_ City L Got Site/Acreage <br /> Owner's Name Address , Phone <br /> . , f t <br /> ontr or "�Atl es Wu 1c ase N . Phone <br /> i TYPE OF WELL/PUMP: NEW WELL 'WELL REPLACEMENT E] DESTRUCTION Cl Dut of Service Hell ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR El OTHER O Monitoring well E3 <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD.+ PROP. LINE <br /> —FOUNGAT10N -A011I6UL SIR'S•WELL- -_....OTHER-WELL— =--rPITS/SUMPS,_ t <br /> s <br /> 1 INTENDED USE TYPE OF WELL' PRO13LEMAREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0Open Sott m! p Manteca Dia'. of Well Excavation Dia.of Well Casing <br /> &Ifo­ffw sticlPrivate 0 Gravel Patk ❑Tracy Type of Casing Specifications <br /> 1'1 Public ('I Other f1 Delta Depth of Grout Seal Type of Grout. _ <br /> I I Irrigation —.Approx. Depth I Eastern � Surfs Soul Installed by <br /> Repair Work-Oone U Type of PuffP` Ia.P. State Work Do <br /> r <br /> Weft Destruction D Well Diamet8r� 13ealittg Maters i Depth <br /> I Awl* <br /> Depth Z 3 biller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i 1 INo septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence_1 Commercial_,_„ Other <br /> Number of living units: NuAor of bedrooms <br /> Character of sop to a depth of 3.feet i Water table depth <br /> SEPTIC TANK. ❑ Type/Mfl Cepaclty_ : NO: Compartments r <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> 1v' <br /> Distance.o nearest: Well Foundation Property Lina <br /> ### LEACHING LINE 0 No. &Leisgth of lines Total length/size <br /> FILTER BED 0 Distance to nearest. f Well Foundation Property Line <br /> E <br /> SEEPAGE PITS 11 Depth — Site Number <br /> k SUMPS LI Diatance'to nearest: Well Foundation Property Line <br /> G t•. . DISPOSAL PONDS CI <br /> I hereby certify that I have prepared thlts application and that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Ctnagent'sthe <br /> y <br /> i Home owner or licensed signatt�ra cfollowing:'"1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ anyporion insuch manna!as td subject to workman's compensation laws of California."Contractor's hiring or,subcontracting signature <br /> candles!fid following: "I cenity that in.0 performance of the work for which this permit is issued,i&hell employ persons subject to workmen's comptinsa- <br /> tion laws of 4Cetifomia'." <br /> The appli mustcallr all required nspnCtiona, Complete drawing an raver side, <br /> '1 Signed Tice: Dar <br /> � te' <br /> XO Y-- <br /> Appllcatlon Acceptod by_ r Data "'—:)LI 'L Area <br /> r I <br /> Plt,or Grout Inspection by L. Date Final Inspection by <br /> Data f4�� <br /> Additional Clom"nu:l <br /> Applic'ot - Return all copies to_ Sen Joaquin County, Public Health Services <br /> ( EfOnmentel Health Permit/Services- <br /> i. t 448 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> INFO AMOUNT Dbt REMITTED K RECEIVEp ey PATE PEltMIT'NO. <br /> • aM 1131 IREV.���61 I -gl' �a <br /> t EM tb2a � �- C.�� [�7AtMOUNIT <br /> / � f <br />