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t i.• ., x <br /> a <br /> J ..�eat - <br /> — rl <br /> g <br /> a� <br /> F <br /> A,PPL1CATION FOR PEWIT <br /> SAN JOAQUIN COUNTY PUBLIC ILEALTU SERVICES <br /> ENVIRO?iMFNTAL IEAL'TH pIVISIO01 <br /> p 0 BO% 2009, STOCKTON, CA <br /> (209) 468--3447 <br /> (Complete In Triplicate) <br /> Applleaelca 1a hereby fade to San JoaQuio County for a perr:tt to construct and/or instau the work herein deacr/bed. Thi! <br /> Application fa hada in <br /> cogslionce vith San Joaquin County Ordinance NQ. 549 and 1862 and the Mule! had Ra6v <br /> lation■ of San <br /> n0e4ULa County Public health Services. <br /> Lot 91re/Ac:-age <br /> Job Address <br /> c?S Pnone <br /> DwMr'a Nsmal` ov'''a, Address <br /> f <br /> ` <br /> Adores —ria LicenseNoza.T- —1. Pnone��: <br /> Gontractbr? ' <br /> TYPE OF WELLIFUMP NEW WELL Z WELL REPLACEMENT Cl DESTRUCTION ❑ put df Service Well <br /> OTHER Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 <br /> ❑ <br /> DISTANCE TO NEAREST: SEPTIC"ANK SEWER LINESU�r DISPOSAL FLC. PROP. LINE S <br /> 2U' ULTURE WELL OTHER WELL PITS/SUMPS <br /> FOUNL,ATION AGRIC <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST^RUCTION SPECIFICATIONS Dia. of Wait Casing <br /> E7 Industnal ❑Opa.>Bottom U Manteca Die.of Well Excevatian SCSI 4111 <br /> Type 01 Launq �t�� -- — Speed+cations <br /> Iy Oom/ttic/Pnwte O(Gtavol Pack C1 Tracy �`,KFp[F Type or Grout!`cr = - - <br /> P,ot,c M Olher C] Dene Depth of Grout Scot <br /> CJ 4nUaupn APWa►. Depth ❑ Eastern Surface Slid installed by <br /> H.P. State Work Done <br /> Repair VJork Done 0 Type of Pump Staling ,Anterial 4 Depth <br /> Wltl Destruction ❑ Wall Dismaler )filler Material A LYpth <br /> Depth— rmitled it ilbhc sewn rs <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIRrADDITION Ll CESiRUCTtGN G &N+ilaoa66ptlw thin 200 Ieel.l p <br /> Installation will s4rvs: Residence— Commercial_ Other <br /> Number 01 living unite:— Number of bedrooms <br /> Water able Depth <br /> Character Of soil to a depth of 3 foot: No,Compartments <br /> SEPTIC TANK 0 Type/Mfg Capacity <br /> Method of Disposal <br /> PKG.TREATMENT PLT.❑ <br /> Distance to nearest: Will Foundation Property Lino <br /> I <br /> Total lengthisiu� <br /> LEACHING LINE ❑ No. 6 Length Of lines <br /> Property Line <br /> FILTER BED n Distance to nearest. Well Foundation <br /> Sus Number <br /> SEEPAGE PITS 11 Depth Property Line <br /> SUMPS LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS O <br /> I htrebv C$llily that I havo pispsred Incl liPPlitsnon and that the work will be done in accor0ance with San Joaquin county of dinancsl, stale laws,and <br /> rules and ngulotrona of the San JQaQuin County I shall not <br /> Homs own$:or hcensad agent's signaluss con'141 the IpilOwinq "I Certify that m the perlOrma '!01 1M work IQf wiSrCh,his permit is ilsuad, <br /> employ easy person in such manner as to b"orns subject to workmen's compenaavon laws of C- bmis."COMreC[Of't h,nng Or wb•convaeunq signature <br /> Cariifrea the following:"I Certify that in the Pert Orm+nc!of the wore for wh,ch his pea mit U iasueo,I shad amplOY persons fubletl l0 workmen's Companu <br /> lion taws of C641ornia", <br /> The appliun IE�aU for r teed psc ions ComWete drawing on fs•ofss redo , <br /> Signed X Lit x, <br /> FOR DEPARTMENT USE ONLY <br /> Dots <br /> Ares <br /> Applicltl0n ACCeptad by <br /> Pll Or Gfbw1 lMetl <br /> p +on by <br /> Dan Final Inspection by Data ^� <br /> iddrtionolComments: <br /> - - _.- _—__. __ ------- ---- _._---- ------------- <br /> UNTY <br /> Applicaat llotura tIl Coote! to: ENti1RONMENTALJOAQUIN OPUBLIC <br /> kit&LTHDIVISIONLPENUITISERVICES <br /> 445 N SAN JOAQUIN, P 0 110x 2009- "X%TON. CA 83201 <br /> FEE AMOUNT DUE AMOUNT REMirrfD CASH RECEIVED By Pall PfstMii NO <br /> INFO <br /> li.'a al <br /> 601111 <br />