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APPLICATION FOR PERYYT <br /> SAN JOAQUIN COUNTY PUBLIC' HBALT TSS ENVIRONMENTAL HEALTH DTVI I <br /> 445 N SAN JOAQUIN, PHONE (2og) t 0q <br /> P 0 BOX 2009, STOCKTON, CA <br /> F <br /> (Complete in Triplicate INV# <br /> ' Applicationis hereby taadeto San Joaquin County for a permit to construct nndlo one <br /> Xne vorX herein described. <br /> application is amde in ec4llance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CovatyaPublic Health Services. J �� <br /> Job Address `wg 5 � d( Cityd:•0'�^t l Lot Size/Acreage <br /> ' Owner°a Nam Address _!�_40 /�• (�(/�It —( <br /> Phone <br /> Contract ! Address_jI . License No Phone —570,57 <br /> ' TYPE Of WELL/PUMP; NEW WELL 0 WELL REPLACEMENT n DESTRUCTION El Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> ' DISTANCE TO NEAREST: SEPTIC_TANK _ SEWER LINES DISPOSAL FLO. _ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private L"i Gravel Pack ❑ Tracy Type of Casing_. Specification <br /> I1 Public f:t Other n Delta a Depth of Grout Seal Type of Grout <br /> I I laigalion -_,_Approx. Depth I I Eastern Surface Seal Installed by <br /> ' Repair Work Done 0 Type of Pump H.P. State Work Dons w —- <br /> Wd Destfuction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material A Depth - <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDfTION I I DESTRUCTION 111No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: ReAsidence Commercial® ther <br /> Number of Wag units. �_d — Number of beacims 9 <br /> ' Character of soft to a of 3 feet: Water table depth —70 <br /> SEPTIC TANK. Too/Mfg Capacity OQ No, Compartments IQ <br /> PKG. TREATMENT PLT. O / ' If Method of Di'posal <br /> Distance to nearest: Well a Foundation Property Lane <br /> LEACHING LINE No, b Length of lines Q Total length/size 0 <br /> FILTER BED ® Distance to nearest. Well Foundation WProperty Line.i <br /> SEEPAGE PITSDepth Size,�5,�L�es ' J lumber <br /> SUMPS Ll Distance to nearest: Well Foundation _ Property Line _ - <br /> DISPOSAL PONDS El <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 <br /> rules and regulations of the San Joaquin County <br /> Ham owner or licensed sWCs signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shell not <br /> employ any person in such mennr as to become subject to workman's compensation laws of Cslifamis."Contractor's hiring or subcontracting signature <br /> candies the following' "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion iswe of California." <br /> The applican t cap f required inspoptien. Complete drawing on reverse laid. <br /> Signed Title: yj s Date: <br /> FOR DEP TMENT USE ONLY <br /> Application Accepted by—raj Date <br /> Ph or Grout Inspection by ��/ Datrr�" !% .L Final Inspection bq <br /> AddlNonal Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health'Services <br /> ' Pnviroomental .Health Permit/Services <br /> /t 445 M Sao Joaquin, P d Boz 2009, Stkn, RA 95201 <br /> 1 \� <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED!Y DATE `yJ4 VoC�w4f <br /> 'EN 13-21lREV.9i0151 <br /> EH ha.Ml ! 111 O`'iJ <br />