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APPLICATION FOR PERMIT <br /> t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> (209) 468-3447 <br /> TRES l YEAR. FROM DATE I SSU <br /> t�l /PO(COmplete in Triplicate) <br /> Application Is hereby made San J A County for a permit to construct end/or Install the work herein described. This <br /> application is made in vi San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. _N (_ <br /> ilXW7 <br /> Job Address L ' I P4COti1 5( r City' 'Lot Size/Acreage <br /> Owner's Name MCC em; Address <br /> t� +�Phone <br /># ContractoAddress a ` <br /> License Phone <br /> t TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service WeII Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHER Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK C.7 <br /> SEWER LINES p15ppSAl FLD. PROP. LINE <br /> 4 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _10- 1$ �� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS kk� ! <br /> f_l industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation ft— <br /> F-14 <br /> Domestic/Private O Gravel Pack ❑ Trac <br /> y Type of Casingsa"orts <br /> M PublicCl Other p Delta Depth of Grout Seal <br /> ation t <br /> 0 Irri <br /> 8 ._... Approa, Depth b Eastern Surface Seal Installed by :til <br /> Repair Work Dons 0 Type of Pump' H.P. Slate Work Dona_ <br /> Well Destruction O Wait Diameter Sealing Material i Depth <br /> t 2 <br /> -Depth Piller Material i Depth (/ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION Ct DESTRUCTION CI INo system septic p permitted if public 5nwer is <br /> ` <br /> tnsrallation will serve: Residence• ; Commercial�..,• Other available within 200 feet,) L11t <br /> Number of living units: Number of bedrooms LJi <br /> Character of a0 to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg<� Capacity , No. Compartments <br /> EKG. TREATMENT PLT. G7 i <br /> Method of Disposal <br /> Distance to nearest: Weil Foundation_ Property Line <br /> LEACHING UNE C1 No. 8 Length of lines <br /> FILTER BEDTotal length/sirs <br /> F) Distance to nearest: Well Foundation Property Line <br /> l <br /> SEEPAGE PITS 11 Depth Sire <br /> Number <br /> SUMPS <br /> LI Distance to nearest: Wall Foundation <br /> DISPOSAL PONDS ' C1 ----- Property Line <br /> I hereby certify that'l have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br /> rules and regulations of the San Joaquin County <br /> HOMO owner or licensed agent's signature'certifies the following; "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 /> .Certifies the following; "I csnify.that in the performance of the work for which this permit is issued, I shall amplo <br /> tion laws of California." — y persona subject to workman's compensa- <br /> tion <br /> t <br /> The applicant c I r inspections. Complete drawing on rse <br /> Signed <br /> Title: <br /> Date: <br /> FORD PA MENT USE ON <br /> Application Accepted by <br /> - Date tea �+L Q <br /> Pit or Grout Inspection by Date <br /> Final Inspection by' Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> HNVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P 0 BOX 2009, 3TOCKTOH, CA 85201 <br /> IFNFOEEAMOUNT DUI: AMOUNT REMITTED CK <br /> CASH RECEIVED 9Y DATE PERMIT'NO. <br /> . <br /> 9H 1 .24 1REV,I/r S! <br />