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LZ,.- rf <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> P O BOX 2009, STOCSTON, CA 95 <br /> (209) 468-3447 <br /> Y R Egou 5 <br /> (Complete in Triplica �Y <br /> Application is hereby made to San Joe uin Count for a <br /> application is made in campllaace with Baa Joaquin County ordinance aandcip <br /> �� y;� r� <br /> Joaquin County Public Health Services. VOtK' rein described. This <br /> t 4e and Regulations of Ban <br /> Job Address � �i%� �nq/I <br /> City Lot Size�Ai�$ge ley <br /> Owner's Name Address <br /> SPhone <br /> Conlracta � Address <br /> License No 9 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ I'hon — L <br /> WELL REPLACEMENT C7 DESTRUCTION Cl Out o' Service Well ❑ <br /> PUMP INSTALLATfON"q. SYSTEM REPAIR ( ( <br /> DISTANCE TO NEAREST; SEPTIC TANK ""� OTHER D Monitoring Well [7 <br /> , SEWER LINES ___,�� DISPOSAL FLD. <br />{ FOUNDATION AGRICULTURE WELL PROP. LINE <br /> tNTENDED USE OTHER WELL PITS/SUMPS <br /> TYP 0 WELL PROBLEM AREA <br /> n Industrial -. � CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom D Manteca Dia. of Well Excavation <br /> Y Public ticJprivate 0 Gravel Pack D Tracy T Dia, of Well Casing <br /> T Public Type of Casing Specifications <br /> C] Other ❑ Delta Depth of Grout Seal J. <br /> G Irrigation .� Approx''Depth ❑ Eastern Type of Grout <br /> Repair Work Done t j Surface Seal Installed by <br /> Type of Pump <br /> Well Destruction �' H.P. / State Work Done <br /> D Wel! Diameter� � Sealing Material ♦ Depth `,f <br /> Depth t Filler Material i Depth <br /> TYPE OF SEPTI. WORK; NEW INSTALLATION 0 REPAIR/ADDItI(JN L7 DESTRUCTION G {No septic system permitted if public sewer is <br /> Installation will serve; Residence­:! available within 200 feet,) <br /> Commercial Other <br /> Number of bedrooms <br /> Number of living Unita: <br /> ` <br /> Character of soil to a depth of 3 feet: ..t —� f <br /> SEPTIC TANK. O- Type/Mfg t Water table depth f] <br /> PKG. TREATMENT PLT. ❑ Capacity__. No. Compartments <br /> ' Method of Di <br /> Distance to nearest: Well Disposal <br /> --�.._ Foundation�� property Line <br /> LEACHING LINE Y EY No. & Length of lines <br /> FILTER BED n Distance to nearest: yVey Total length/sire <br /> Foundation a <br /> t ti --�T Property Line <br /> SEEPAGE PITS <br /> 11 Depth I <br /> SUMPSSrrO Number <br /> LI Distance to nearest:'- Well <br /> DISPOSAL PONDS Foundations Property Line` <br /> I hereby certify that I have,prepared this application and that the work w4l bone in a c rdance with San Joaquin county ordinances, stela laws, and a <br /> rules and regulations of the Sen Joaquin-County _� ' T <br /> Home owner or licensed agan{'s signature Certifies the lollowing; '! certify that in the <br /> employ any person in such manner as to become subject to workman's compensation Laws of California." Contractor's hiring or sub-contracting signature <br /> performance of the work for which this permit is issued, I shall not <br /> }certifies the following: "I certify that in the performance of the work for which this <br /> tion laws of California." permit is issued, I shall employ Persons subject to workman's Compenae <br /> Thea t <br /> applicant must for all r ed inspections. Complete drawing on re so side, <br /> Signed , <br /> Tide: <br /> Data: <br /> FO �EPARTMIENT�USE,o�NLy <br /> Application Accepted by <br /> Pit or Grout Ins Area <br /> 'Inspection by <br /> Additional Comments; Date <br /> ' Final Inspection by Date Z 9/ <br /> Applicant - Return all copies to: t Q _ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN. P O BO% 2008, STUCKTON, CA 85201 <br /> rs• .� <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE <br /> EN 11. 41WEV.+iKsr SOD PERMIT'NO. <br /> Ek 1./•26 G a <br />