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APPLICAT OON FOR PERMIT ; <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ;P 0 BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> i RATE ISSU <br /> t (Complete in Triplicate) <br />'F <br />[ Application is hereby made to SaniJosquin County for a permit to construct and/or install the work herein described. This <br /> application is made in tompliance;vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> City 2JOLot Size/Acreage �t <br /> Job Address (/ a <br /> Phone <br /> Owner's Name <br /> dress 7 <br /> � - l <br /> Contractor <br /> 5 ddress License Na. / Phone <br /> TYPE OF WELLIPUMP. ,NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl <br /> OTHER ❑ Monitoring Well [� <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ / <br /> iPROP. r <br /> l~ LINE � <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. <br /> i FOUNDATIAGRICULTURE WELL _---OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION UJ <br /> Dia. of Weil Casing <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Specifications <br /> - <br /> Type X/Grayei Pack ❑ Tracy Type of Casing Type of Grout / <br /> ttt ❑ Puhlic CA olper ❑ Delta Depth of Grout Seal <br /> ci Irrigation RW Approx, Depth ❑ Eastern Surface Ssal installed by <br /> t Repair Work Done 0 Type of Pump H.P. State Work Dona <br /> Sealing Material i Depth G <br /> Well Destruction ❑ Weil Diameter Biller Material i Depth <br /> { Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIRIADDITION 0 DESTRUCTION CI (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> l Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> r Character of soil to a depth of 3 feet: Water table depth <br /> ` SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> G <br /> PKG. TREATMENT PLT. Method of Disposal (b <br /> t <br /> C1 <br /> r <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Properly Line "Z <br /> l SEEPAGE PITS t I Depth Size Number Cil <br /> SUMPS Ll Distance to nearest: Well foundation Property Line t� <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state Iawc, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not <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 /> .L certifies the following: "I certify that in the performance of the work for which this permit is iesued, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applica us requi Complete drawing on reverse ids12e / <br /> Z_ <br /> Signed <br /> ills: Date: <br /> _ � R DEPARTMENT USE O LY <br /> Application Accepted by Date Area <br /> 9� <br /> Pit or Grout inspection by i ate d Final Inspection by J ' `� Data 3 Z <br /> tL49, L4 JQM jrd["� <br /> Additional Comments: <br /> ` Applicant — Return all copies to: SAN JOAQUIN COUNT PUBLI SALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOS 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DUE AMOVN7 REMITTEp CASH'w, AECEIVED BY DATE PERMIT'NO. <br /> INFO �t2 .. Z,�4 1.11 <br /> .'EN 1�7�IAEV.i A U 5 � Q 0) ___1 �' ! 12% Q 4 � 2�Z <br /> k to:�•as <br />