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i <br /> i APPLICATION FOR PBRMI <br /> SAN aoAQUIN COUNTY PUBLIC HEALTH 144MRS 00 l �Y <br /> PsNVIR AiiHEA .TPAPTNI5 <br /> 445 N SAN _(„=1'W N (2091) ?Qr,,,,- <br /> P O BO% 20 ;'' STO� 'ON, C <br /> �! T E%P c Y W) DE.ISSUED <br /> ERlli <br /> (Complete in Triplicate <br /> 11 Application is hereby made'lto San Joaquin County for a permit'to construct and/or install the work herein described. This <br /> application is made in compliance vith'San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of Ban <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> 1 <br /> Owner's Name Address Phone 53 J <br /> 7 Cantraclor Address License No. Phone <br /> ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.1 DESTRUCTION ❑ Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER D t Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPEjOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> !i C] Industrial 0 Operi Bottom D Manteca Dia. of Well Excavation Dia. of.Well Casing <br /> I„ Domestic/Private Cl Gravel Peck D Tracy Type of Casing i Specifications tF' <br /> i] VI Public n Other Cl Delta Depth of Grout Seal Type of.Grou <br /> I I Irtigation —.Approx. Depth I I Eastern dace Seal Installed by <br /> k Repair Work Done U Type of Pt"TM 0,1A H.P. Slits Work Done Q <br /> Wed Destruction ❑ won Diameter ! ' scaling Material i Depth fes+ <br /> Depth Filler Material i Depth <br /> � <br /> 1' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I iNo septic system permitted if public sawer is <br /> i available within 200 feet.) <br /> kInstallation will serve: Residence.L I •Commercial -Other- <br /> !.Number <br /> ther:Number of living units: Number of!bedroom ?�,..,.....� ��� <br /> 'Character of toll to a depth of 3 lest: ? ? Water table.depth A <br /> t SEPTIC TANK. O TypslMfg Capacity - No. Compartmen <br /> ,c PKG. TREATMENT PLT.❑ y t Method of Dispo A 19TSUL 14 <br /> Dis;tshce to nearest: Well FlxOnd¢} } Property Line <br /> LEACHING LINE ❑ Nb. 6 Length of lines 'I .Toter length/size— <br /> FILTER <br /> ength/size FILTER BED ❑ Distance to nearest. Well ; Foundation. ' Property Line—atilRQ <br /> SEEPAGE PITS 11 OeptlSSize Number <br /> 1 SbMPS LI Distance to nearest: Well I`Fouridafion ! Property Line <br /> j DISPOSAL PONDS ❑ <br /> I hereby certify that I have preparect„his application and that.lhg work will be done in ac-&(dancd with San Joaquin county ordinances, state laws, and . <br /> rules.and regulations of the San Joaquin County i <br /> Home owner or licensed agents signature certifies the following:” 'I Certify that in the perfofmance of the work for which this permit is issued, I shall not <br /> employ any per in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies t r;"I certify that in the_performance of the work for which this permit is isiued, I shall employ persona subject to workman's eompensa- <br /> j tion laws f i <br /> 4 i <br /> The st call for an ed�Ini. Compete drawing FTUSE <br /> e. <br /> Signed itle: + Data: <br /> PARTEOR AEOL <br /> E .. .�.. ,.. _._..._ <br /> if. Application-ft'tapted.hy - ;.r. _. _ . . . ,. • -`Daii3- - - -Alga.,.-.. _, ... _ ,... _. . .. <br /> {I <br /> j Pit or Grout Inspection by Date Final Inspection by , . to <br /> I - _ .._._ _. _ .. ... <br /> l0 <br /> it <br /> 1. Additional Comments: x7elz.4 <br /> + <br /> Applicant - Return all copies to: San'Joaquin County Public Health vices <br /> Environmental Health PermitlServices <br /> 'I,, 'I 445 N San Joaquin, P O Boa 2008, Stkn, CA 95201 <br /> vIN 0 Yc l AMOUNT DUE ;. AMOUNT REMITTED) CASH CK 8 RECEIVED BY DATE PERMIT•NO. <br /> . EN <br /> EN/414-26124 1REY.r i b s! q5,9d <br /> � <br />