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�3 <br /> APPLICATION FOR P ITQ� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH R <br /> ENVIRONMENTAL HEALTH DIVIS <br /> 445 N SAN JOAQUIN, PHONE (209)4 <br /> P O BOX 2009, STOCKTON, CA 9 <br /> Y 2= Assimp <br /> o <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the vor <br /> application is a*Nde in coWliance with San Joaquin County O,dinsnce No. 5L9 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> l <br /> Job Address /V OSE / Cifyey Lot Biu/Acreage <br /> I�,w f <br /> pwnsr's Name (�• ,,��1��-a� A��ddres'sff�� ��j/c�s��l3i�r �l} . Phone <br /> Cant{actor �,(%e�LLL _Address r( f f`_ e C/ !�' License Na.�a[s Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Nell Ll <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER D Monitoring Well Q <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C7 Industrial © Open Bortom ❑ Manteca Out. of Web Excavation_ Din. of Well Casing <br /> Cl Domestic/Private 1:1 Gravel Pack C7 Tracy Type of-Casing Specifications <br /> I'I Public f'1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrkistion _Amos. Depth I I Eastern Surface Seal Instaesd by <br /> Repair Work Dons U Type of Pump H.P. State Work Dona <br /> Well Destruction p Well Diantoter Sealing Notarial i Depth <br /> Depth Villar Material 4 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 111No septic system permitted if pubic sewer is <br /> available within 200 fNLI <br /> Installation w#i serve: Residence_k-'1Cornn,.,,W i Other - <br /> Number o1 living units:_J___ Number of bodrooms„:S _ <br /> Chas--of son to a depth o1 3 toot: ._Water table depth +� <br /> SEPTIC TANK O Typo/Mfg Copecity No. Cormpartmsnts <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well . Foundation_ Props" Lite <br /> LEACHING LINE ' No.a Length of lines _ � Tetsl length/size <br /> FILTER BED O Distance to nearest: Wail Foundation j:00t'07 - Property Line <br /> SEEPAGE PITS 11 Depth Size Number_ <br /> SUMPS LI Diatoms to rmweat: Well Foundation Property Lino <br /> DISPOSAL PONDS O <br /> I hereby certify that I have prepared this application and that the worts wilt be done in accordance with San Joaquin county ordinances,state laws, and <br /> rukss and regulations of the Son Joaquin county <br /> Homo owner or licensed agent's signature certifies the following: "I cenity that In the performance of the work for which this permit is issued, i shall not <br /> employ any person in such manner,,a to became subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signatuts <br /> cartifies the following: "I unify that in the performance of the work for which this perrrdt is issued,I shall employ persona subject to workman's Cormpenpt- <br /> tion laws of CaiHornls." <br /> The applicant must callfa icedInspections. Complete drawing on rover <br /> Signed "� Title: C&A�L Date: <br /> _ EPA E2�!� <br /> Application Accepted by ..� d1p GZ U <br /> Pit or Grout Itvpeetion by Date Final Inspection by Dna <br /> Addhlonal Comments: 'v <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Hot, <br /> lt Permit/ServiceB <br /> 445 N San Joaquin, 0 Bo: 2000, Stkn, CA 201 <br /> ' INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED(iY DATE PEAMR NO, <br /> '. Ily 4, <br /> • fM1�IRtV_tr�6t !� // /P� r B4O C � / CJ /�� <br />