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APPLICATION FOR PERMIT °— <br /> �/ 1111110 .4 <br /> BAN JOAQUIN COUNTY PUBLIC HEALTH SERVI <br /> ENVIRONMENTAL HEALTH DIVISION I <br /> P 0 Hoar 2009, sTOcxT N, CA 95201 <br /> (209) 468--3447 <br /> APR <br /> (Complete is Triplicate) 8 1991 <br /> Applicatioa to hereby glade ton <br /> o Sag Joaquin County for a peredt to cstruct &War its Wit ribed. This <br /> eppliestioa in sande in complisn" with San Josqu n County Ordinance Ifo. 544 and 1862 and th�� of Says <br /> Jeepla County Public Health Services. <br /> .fob Address ��� IrZ�Y u[PQ City k _ Loot Site/Acreage <br /> Owlwrs Name Address phpne <br /> F <br /> Contracts Address a License No. Z_ _._�Phone 460 <br /> PE WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION CI Out of Service Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION IS -_ AGRICULTURE WELL OTHER WELL PITS/SUMPS �. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS cr <br /> n Induce w ❑Open Bottom ❑ Manteca Dy. of Well Excavation Dia. of Well Casing <br /> 0 Domestic/private 0 Gravel Pack D Tracy Type of Casing txd,-4A POLI Specifications <br /> M Public fa Other CI Delo Depth of Grout Seal /B 14:1, /S Type of Grout Ce`^a''t`! <br /> CJ Irrigation f Ntw<�',.Apprax, Depth if Eastern Surface"Seal Installed by <br /> Repair Work Done E3 Type of Pump N.P. State Work Done_ <br /> Well Destnrcdon ❑ Well Diameter SaaLag Material i Depth <br /> Depth Tiller Naterial 4 Depth <br /> TYPE OF SE IC WORK: NEW INSTALLATION 0 REPAIR/AOOITION Cl DESTRUCTION G INo septic system permitted U public sewer is <br /> 1 <br /> available within 200 lost.) <br /> l � <br /> Installation will serve: Residence_ Commercial_ Other LJ` <br /> Number of living unite: Number of bedrooms <br /> Cherseter of*0 to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capaclsy No. Compartments <br /> PKG. TREATMENT PLT.CI Method of Disposal <br /> Distance to nearest: Wall Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of linos Total longth/size <br /> FILTER BED ❑ Distance to nearest: WON Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS Ll Distance to neerost: WON Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I flea prepared this application and that the work vviq be done in accordance with San Joaquin county ordinances. stats laws, and <br /> rules and reguleliono of the San Jwuln County <br /> Nom!Owner or licensed agent's signature oeniries the following: "I cenify that in the performance of the work for which this permit is issued, I shelf not <br /> s nploy any person in such manner as to become subject to workman's compensation laws of California."Contractors hirin or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shag a t to workman's compsnss• <br /> tion laws of Californis." <br /> Ths oppgca t for all reteuirad Complete drawing on reverea side. <br /> Signed Title Date: <br /> rt FOR DEPARTMENT USE ONLY <br /> Application Accepted by Or6oDat r Area <br /> Pk or Grout Inspection by Date_—1;?= jT,. Final Inspection by pats ' <br /> f <br /> Additional Comments: <br /> Applicant - Return all copies ton SAN JOAQUIN COUNTY PUBLIC HEALTH SSRVICSS <br /> ENVIRONMENTAL BBAALTH DIVISION PERMIT/SBRVICBS <br /> 445 N SAN JOAQUIN, P 0 BOX 1000, ST=TON, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED EIVEO by DATE PERMIT NO. <br /> INFO <br /> . IN 13-24 Ir1EV.u Aso ' <br /> 1"14416 <br />