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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION :,� <br /> P O SOS 2009, STOCKTON, F CA 3520 . ,: . TJ <br /> (208) 468-3447F, <br /> �T NUIRM I YEAR XM RM am= <br /> (Complete in Triplicate) <br /> Applies. too Is hereby msde,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> applicatioa is made in coWlianee with Sats Joaquin County Ordinance No. 549 and 1852 and the Rules and Regulations of San <br /> Joaquin. County Public Health Services. <br /> Job Adds" �a, City Lot Size/Acreage <br /> Owner's 4artur E-��lt1�l &Sad t_\1CW Address Phone r c <br /> Contaaci r CAP, Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT © DESTRUCTION O Out of Service Well, <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 13 OTHER 13 Monitoring Well L7 <br /> DISTAN E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED.USP_ 'TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M tndustriai 0 Open Bottom ©Manteca Dia, of Well Excavation Dia, of Well Casing <br /> U Domestic/Private Cl Gravel Pack 0 Tracy Type of Casing Specifications <br /> C3 Pubft CI Other l] Delta Depth of Grout Seat Type of Grout <br /> 0 tr6gation _ Approx. Depth 0 Eastern Surf late Said InstalW bV <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter <br /> Sealing Materials Depth <br /> Depth F-111er Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/A00ITiON 0 DESTRUCTION G lNg septic system permitted it public sewer m <br /> available within 200 feet.) <br /> tnvallation w4II serve: Residence of Commercial Other <br /> ' Number of IMng unit`: . Number of bedrooms <br /> T <br /> Character of Boll to a'depth of 3 feet: Water table depth <br /> SEPTIC TANK D Type/Mfg Capacity_ 49.0 No. Compartments <br /> PKG. TREATMENT PLT.0Method of Disposal <br /> Distance to nearest: Well ftY <br /> Foundation. Property Lin® . <br /> - 4 <br /> LEACHING LINE 9- No. & Length of lines "� Total length/size <br /> FILTER BED Ll distance to nearest: Wail Foundation Property Line <br /> SEEPAGE PITS I I Depth Sise --- Number <br /> SUMPS LI Distance to nearest: Weil Foundation Property Line <br /> DISPOSAL PONDS Q <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 taws, and <br /> rules and reputations of the San Joaquin County <br /> Home owner or licensed agent's signature camifies 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:­f certify that in the performance of the work for which this permit is issued,I shelf employ persons subject to workman's compensa• <br /> tion lays of Califomla." <br /> The applicant ffXUs1 call for all required PSPO.Ctlons. Complete drawing on reverse side, <br /> Signed)CL_ rC C t! Tits. �Ld �' ._ Date: / <br /> f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Ares 14 <br /> Pit or Groat Insptsetfon by Date Final Inspection by 4�� Date_L�. ,q <br /> ftional Comments: <br /> .ppliceat a Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL REALTU DIVISION PSRlttT/ssRvICEs <br /> l 448 N SAN JOAQUIN, P O.$OX 2009, STOCKTO# CA 95203 <br /> IFEE /AMOUNT DQS pAJMOVNT REMITTED ASH RECEIVED BY OATtE PEAMI-r N0. <br /> H 71•x <br />