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APPLICATION FOR PERMIT <br /> j PAYMENy SAN JOAQUIN COUNTY PUBLIC HEALTH SHRVICES <br /> RECEIVED BNVIRONHXNTAL HEALTH DIVISION <br /> SCP 0 g 19P O Bog 2{209, <br /> p9)S4OCK ON, CA 95201 <br /> 3447 <br /> SAN JOAQIJIN CG!IrgTY <br /> VEL; <br /> PUBUC HEALTH SE?VICESPANITS SEP # <br /> 'Vhl1RONMENTAL HEALTH GI'►riSlt7tf (Complete in Triplicate) LNVIRONMIENTAL HEALTH <br /> Application is hereby made to Baa .)'oaQuin County ror a permit to constructEpplicaand/or iastmil <br /> Joaquin County <br /> made in coml+lirnca with Ban Jnequia County OrdiaanCc Ro. 549 and 1962 end the Itulea and Regulations of Th'Sans <br /> Joaquin Cotutty Public Health Services. <br /> Job Address _ City Bise/Acreage <br /> Owner'r Na - PA- <br /> dress (� !t5t <br /> Phone <br /> Contra c re enae <br /> TYPE FTOF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [� DE&TRUCTI flf service M111 ❑ <br /> tNil <br /> PUMP INSTALLATION SYSTEM REPAIR 171'' OTHER ❑ Monitoring Vail Q `� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .._ DISPOSAL FLM, PROP. LINE (n <br /> FOUNDATION . - AGRICULTURE WELL OTHER WELL •PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTAUCTION SPECIFICATIONS <br /> Cl Industrial 13 Open Bottom (3 Manteca Ora, of Well Excavation <br /> Dia, of Well Casing <br /> 4W5�stic/Private 0 Gravel Peck 13 Tracy Type of Casing Specifications <br /> ❑PrlbNe 1:1 Other ❑ Delta Depth of Grout Seal _ �1 <br /> Type of Grout <br /> M Irrigstion ApFox. Depth ❑ EasternSurface Seel Installed by <br /> Repair Work Done Type of Pump H.P. Q <br /> Will Destruction O Well Diameter Sealing Meter-I A DeptState Work Done <br /> h <br /> Oepth _ Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITfON 0 OESTRUCTION 1J Ilio septic system permitted if public sewer in y <br /> Installation will serve: Rssidencey;,_t^ Commercial Other available within 200 test.} <br /> G Number of living units: t� .INumber of bedrooms <br /> Character Of soil to a depth of 3 feet: <br /> SEPTIC TANK, C) TypNMfg Water table depth <br /> PKG. TREATMENT PLT.0 Capacity-- No, Compartments <br /> Mletinee t0 nearest; Well Foundation. PrMethod of Disposal <br /> operty <br /> LEACHING LINE <br /> CI No. 8 Length of linea <br /> FILTER SEDTotal length/tile <br /> n Distance to nearest: Weft foundation_�� Property Line <br /> SEEPAGE PITS <br /> 11 Depth <br /> ._Site may, Number <br /> SUMPS Lt Distance to naareat; WNI Foundation <br /> DISPOSAL PONOS Property Line <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 rhe San Joaquin County <br /> Home Owner or licensed agent's signature cenifiss the following; "I certify that in the performance of the workfor 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." Contractors hiring or subs contrscting signature <br /> eerti6e4 the following;"I cenify that In the performance of the work for which this permit is issued,t shall sm la <br /> tion laws of California." �. P V Persons subject to workman's compenia- <br /> The applicant must e pf an required tions. Complete drawing on verse aide. <br /> Signed ; Title: Date: *11 ` <br /> •' ' -� . FOR DEPARTMENT USE ONLY <br /> Application Accepted by _. <br /> - Date X Area• ,� <br /> Pit Of Grout Inspection by D81 ' <br /> -- Final Inspection by ate2— <br /> Additional Comments: <br /> Applicant - Return ail copies to: BAN JOAQUIN COUNTY PUBLIC HEALTH SgRVICBS <br /> ENVIRtNMENTAL HEALTH DIYI46ION PROMIT/SERVICES <br /> 445 N SAN JOAQUIN, P o BOE 2000- 87=?ON, CA 05301 <br /> FEE IMOUNT DUE AMOUNT REFtJTTEO >< <br /> INFO CASH RECEiVED Sy DATE PERMIT'No. <br /> .tM 1}71 taEV,v■ <br /> or Q� dm <br /> EH 4.31 r7ti. `r ,4�-b0` 3��y 64 3/2;- <br />