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/ APPLICATION FOR PTRYI <br /> SAN JOAQUIN COMITY UBLiCHR ICES <br /> �J SNVI$ON LRNfiAL HEALTH 1 I NTAL KEI��_ <br /> 445 N SAN JOAQIIIN, PRONE (20 � Th <br /> P O BOX 2009, STOCKTOIN, C <br /> PEMIT EXPIRES 1 YEAR <br /> (Complete in Triplica # <br /> Application Is bereW made to San Joaquin County for a permit to construct s <br /> epplieation Is made in conialance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressAK <br /> O Cit Lot Size/Acreage <br /> Owners Nam"�kr/'�� c^•x�► l� Address <br /> Contract "dress a ErysJ`It,./ AJb1�x4Licertse No. ,'�_Phone <br /> TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION 0 Out of Se ce Well <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well /6'L <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 7.Q AGRICULYURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r, <br /> ❑IndustriN ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �f,2' Dia. of WON Caewq <br /> * Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing IAIiC Specifications <br /> 11 Public n Other f 1 Delta Depth of Grout Soso, Type of <br /> I I laiprtion _.Approx. Depth I I Eastern Surface Seal Imsta" / — <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Wag DepWCtion O WMI Diarnetot Sealing Material A Depth a �. <br /> Ste / <br /> Depth Fillw Material A Depth tft- 1r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DES TION I 1 (No septic system permitted if public sower is <br /> available within 200 feet.) <br /> Installation willsorve: Residence— ComnNrcial_ Othor ' <br /> Number of by ft unite: Number of bedrooms <br /> Cherecow of soli to a depth of 3 feet: Water table depth Q <br /> SEPTIC TANK O Type/Mfg Capacity -maartments 1 <br /> PKG. TREATMENT PLT.O PAY <br /> A Disposal <br /> Distance to nearest: WON Foundation <br /> a <br /> LEACHING LUQ ❑ No. 8 Length of firm / <br /> 1. low <br /> FILTER BED O Distance to nearest: Well Foundation <br /> 1 <br /> SEEPAGE PITS 1 I Depth Sire EWIWJ um r <br /> SUMPS, LI Distance to rnomew: Well Foundation Property Lim <br /> DISPOSAL PONDS ❑ <br /> 1 hereby Certiftr that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,state lows, and <br /> rules and.AMpAstions of the San Joaquin County <br /> Howe owner or konead epertt's signature certifies the foibwinp: "1 certify that in the performance of the work for which this permit is issued,I shell <br /> employ any parson in such manner as to became subject to workmen's compensation laws of California."Contractor's hiring or sub-contractft sWolurs , <br /> oerNR- the fofiowwtp:"I certify that in the performance of the work for which this permit is issued,I shelf employ persons subject to workman's compenss- <br /> don Is"of CaNfomi"." <br /> The sppNt:aMfor Complete drawing on rovers si <br /> S*"X At '0Thle: _ Date: -7 <br /> DEPARTMENT USE ONLY <br /> APP ASA by DEPARTMENT <br /> J4,4 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services .r+••+• �� �^0 <br /> Environmental Health Permit/Services Jr" G-0—J <br /> 445 N San Joaquin, P O Box 9009, Stkn, CA 95201 <br /> INNFFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED SY GATE PERMIT'N0. <br /> . <br /> IN 13-11(Aft v a s► Ag. A D@ <br /> 07 <br /> err a <br />