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APPLICATION FOR PERMIT <br /> + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ]P 0 BOX 2009, STOC%TON, CA 95201 <br /> (209) 468-344? <br /> 3420 � <br /> YEAR,PRQM 'Da g IQSUIM <br /> (Complete in Triplicate) <br /> 4 Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Joaquin County Public Heallth t3 <br /> application is made in coth Servicee.ce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> )C Job Address 3 0 I . L✓Q <br /> City Lot Site/Acreage <br /> Owner's Name a a Address <br /> _. - ,• ..T�"``-°— Phone <br /> X• Contractor 'Address e a/0y0Aa;�� <br /> � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 License No. Phone DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 BOltOM ❑ Manteca Dia. of Well Excavation <br /> U Domestic/Private C) Gravel Pack.: ❑ Trac Dia. of Well Casing <br /> Y Type of Casing Sifications <br /> a Public i"1 Other � pec <br /> ❑ Delta Depth of Grout Sea! <br /> t'J Irrigation , Type of Grout <br /> —Approx. Depth ❑ Eastern Surface Saul Installed by <br /> 'Repair Work Done 0 Type of Pump H P <br /> Well Destruction D Weft Diameter # _ Sealing Material i Depth State Work Done_ <br /> Depth Filler Material i Depth {� <br /> TYPE OF SEPTIC WORK; NEW INSTAREPAIR/ADDITION Lf DESTRUCTION (No septic system permitted if public sewer is <br /> i <br /> Installation will serve: Residence._._, #Commercial_ Other available within 200 feet.) <br /> Number of living-units: - Number,of_bedrooms _ <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. Water table depth <br /> Type/Mfg LC" ^ 1" <br /> PKG. TREATMENT PLT, 0Capacity No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE C1 No. & Length of lines C <br /> FILTER BED I-1 r Total length/size <br /> Distance to nearest: Well Foundation _ Property Line <br /> I <br /> SEEPAGE PITS 11 Depth I Size <br /> Number <br /> SUMPS � <br /> Cl Distance to nearest: Well Foundation Property Line <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 laws, and t <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agents 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 ast os perms issued, I shall employ <br /> subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the folio wi "I certify that it the pq otmance of the work for which this i <br /> lion laws of C orn11-1 t D Y persons subject to workman's compansa• <br /> The applican mu for it required ins r <br /> q pe, ions. Complete drawing on re arse ids. <br /> }( Signed Title: <br /> Date' ^ <br /> OF[ DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date 5 `� Area <br /> Pit or Grout Inspection by Date <br /> ---� Final inspection by e ate <br /> Additional Comments: ; <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC•HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 448 N SAN JOAQUIN, P 0 2008, STOCKTON, CA 135201 <br /> FEE <br /> INFO AMOUNT Ott£ AMOUNT REMITTED GK <br /> ��(� lJ�J RECEIVED 8Y DATE PERMIT N0. <br /> CH1J.7�IREV.FinSi (�� 7 V _ 7Y� �3LG <br /> EH 1�.� 9 � <br /> z <br />