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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC IEEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> 1209) 468-3447 <br /> P RS T XPIRES 1 YEAR FROM D TE I ,�iL6Q <br /> (Complete in Triplicate) <br /> Application is hereby aado.to San Joaquin Courty for a permit to construct and/or install the work herein described. This <br /> application is made in conipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Servlc:a. <br /> �.� 7 City Lot Site/Acreage_. <br /> Job Address <br /> Owner',, <br /> wnei a Name ' Phone <br /> Contractor_Yl� Addiers L cense No. Phone <br /> TYPE OF WELL/PUMP. NEW WELL j NrELL REPLACEMENT n DESTRUCTION O Out of Service Well O t <br /> PUMP INSTALLATION C SYSTEM REPAIR .l OTHER O <br /> Monitoring Well tj <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES OTHER W FLD. PROP. <br /> SPSUMPS _ <br /> FOUNDATION _ AGRICULTURE WELL OTHER WELL 6 <br /> INTENDED USE TYPE OF WELL PROULEM AREA CONSTRUCTION SPECIFICATIONS_ Oa of Well Casing <br /> n Industrial O Open Bottom ❑ Manteca Dia.of Wall Excavation Spectlic loons <br /> i' Type of Casing <br /> L Dom <br /> estt/Pnvau O Gravel Pack O Tracy Typo of Grout._— <br /> ,l p p„pl,t Ice Other O Ualre Depth or Grout sal <br /> _Approx. Depth ❑ Eastern Suffices Soul Installed by ' <br /> U IruOauon t <br /> `•`� Stets Work Oona <br /> r Repair Work Done U Type of Pump H.P. ' ` $ <br /> h. Sealing Material 4 Dept^ N <br /> West Destruction O well Diameter < <br /> r �y Depth lillar Material 4 Depth /A <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR 9111, DESTRUCTION G lNo evoidabis system 200 frm fed d Wrbl'c so`„er a7 C;09 <br /> V. � 1� <br /> �T Ins!allation will waw: Residence_ Commercial Other <br /> �$t Number of Owing units._ Nu, Jer of bedroom / L <br /> `t CMr4ctor of soft to a depth of]foot: Wales table depth_ <br /> Capacity No.Compartmenu <br /> q v SEPTIC TANK O Type)Mf9 <br /> 'PKG.TREATMENT PLT.11 i Method of Disposal 'F <br /> Distance to nearest: well Foundation_ Property Line �1a <br /> LEACHING LINE O No.8 Length of lines T9tal Isngth/siae <br /> x <br /> ry <br /> FILTER BED n Distance to nearest: west Foundation Property Line �s ; <br /> y. <br /> }, l <br /> SEEPAGE PITS <br /> 11 DePtlr Sire Number <br /> SUMPS 1 Distance to nearest; Wall Foundation_ Property Lift <br /> Ti <br /> DISPOSAL PONDS O T <br /> Y <br /> m I hsrsby sonify That f Mw prepared thif application and that the work will be dune in accordance with San Joaquin county mdrnanees sate laws ersd <br /> rules end regulations of the San Joaquin County <br /> not <br /> Moms owner or licensed spoof's signature artiiies the follovnrg:"I <br /> certify that in trio performance of the work for which the perm!is issued.I shlH ;. <br /> 1'•�"'"� '� emDby any person M u:ch manner as to become subject to workman's compensation laws of California."ContreePois hiring or sub•tonfreetinp slQnature.; <br /> z ti; tertllNe the following:"I fortify lMt in 1M peAormanco of the work for which this permit is issued,I shall employ Persons subject to workma tompenp J <br /> J lion laws of California,” .yvK <br /> I The applicant must CON for of required Inspections. Comdets drawing on rover"side. <br /> !G <br /> lof� - <br /> Title: <br /> �tlYl2y Dau: <br /> Signed x��.- i�_�_ <br /> d <br /> � FPARTMENT USE ONLY 3 <br /> u ^9 Area <br /> Application Accepted by /(/o <br /> " e aOates Final Inapettion by Due <br /> x s pit if Grout Inspection by <br /> Q�W( •� C�F111CI�SC� �'- oZ•. .;r <br /> i Addltlons Commence: '" 5 <br /> S <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY P"ELIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH LIVISION PERMIT/SERVICES �+5,,`' try <br /> 445 N SAN JOAQUIN, P 0 EO% 2009, ST=TON, CA 95201 <br /> �* rt <br /> c <br /> FEEAMOUNT DUE AMOUNT nEMITTEO RECEIVED BY DATE PERMIT NO. S�� <br /> INFO `F <br /> l/ U <br /> ,�.: --b .r•'1}N III N.v�H . <br /> � w:r.>..+e:.clx>w.ism`F.,-,n.caws.a'w.."•w.:v�..,n.w.+•+ywc.:4ltj4 �'i <br />