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b <br /> Y <br /> APPLICATION FOR PERM <br /> SAN JOAQUIN COUNTY PUBLIC EEAL.rH It <br /> BNVIEONMENTAL HEALTH DIVISIQiI+x •1; <br /> 445 N SAN JOAQUIN, PHONE (200468-34 <br /> P O BOX 2009, STOCKTON, " 9520 <br /> P-MMIT IRE FR 9Z!�Z2F . <br /> (Complete in TriplicatbI <br /> Application ie hereby made to San Joaquin County for a permit to construct and/or inatau the work herein described. This <br /> ayplieation is made !A Compliance with San Joaquin County Ordinance No. 549 and 1852 turd the Rules am Regulations of San <br /> Joaquin County Public Health Services. <br /> .fob Address Z?RCity Lot Size/Acreage <br /> Owners Name Address <br /> Phone <br /> Contraclor Address cense No. d n Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service bell ❑ <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 /> I-) Industrial ❑Olsen Bottom ❑ Manteca Dia.of Well Excavation� � Dia. of Well Casing [� <br /> ("1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications <br /> I"1 Public D Other 11 Delta Dooth of Grout Seal Type of Grout <br /> Irrigation _Approx. Depth I 1 Eastern Surfec Semi Insta4ed by Z (V <br /> Repair Work Done 01 Type of Pump s7 H.P. State Work Done_ u} <br /> Well Destruction ❑ WON Diamstef Sealing Material III Depth <br /> Depth Tiller Material A Depth <br /> TYPE OF SEPTIC WORK.-NEW INSTALLATION I f REPAIRIA004TION I I DESTRUCTION i I lNo septic system pa milled it public rawer is <br /> available within 200 toot.) <br /> installation WHI serve: Residence— Commercial_ Other <br /> Number of living Unita: Number of bodroorm <br /> Character of$oil to a depth of 3 lest: Water table depth <br /> SEPTIC TANK. ❑ Typo/M}g Capacity No, Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well_�^ Foundation . Property Lina <br /> LEACHING LINE 0 No. & Length of lines � Total length/size <br /> FILTER SED 0 Distance to nearest: Well Foundation _ Pro <br /> . , petty Line <br /> SEEPAGE PITS I I Depth _Size Number <br /> SUMPS Ll Distance to naerast: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that i have prepared this rpplieatlon and that the work Will be done in accordance with San Joaquin county ordinances, state Lows, and <br /> rules and raquletions Of the San Joaquin County <br /> Horne owner or licensed agent's signature certifies the following; "I certify that in the perforrnanca of the work for which this permt is issued, I shah riot <br /> employ any person in such mismer as to become subject to workmen's compensation Low.of California."Contractor's hiring or sub con an ' <br /> canities the fnilowft: "I cenity that in the performance of the work for which this �signature <br /> tion few$o}C"16mia" permit is issued,I shall employ persons subject to workman' componsa- <br /> The applicant call for I required InqxR9fts. Complete drawing on reve►s <br /> v <br /> Signed <br /> Title: Oats: <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceplad by <br /> Date Ares <br /> Pk OF Grout lnfpes lion by date Final Inspection by f to <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services`ip �14 0-7 445 H San Joaquin, P O Box 2009, Stku, CA 95201 <br /> Irr}C1�r FEE AMOUNT pt1E AMOUNT REMITTED <br /> INFO H RECEIVED BY DATE PERMIT'NO <br /> 5�•ze <br /> . FN,7-z~fnrv, !S 7§: r�� �� g -4-- <br /> 7� <br /> EH � � <br />