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Of <br /> APPLICATION -f <br /> — <br /> p <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S Vjp c?L LY.a�i <br /> ENVIRONMENTAL HEALTH DIVISIO <br /> 445 N SAN JOAQUIN, PHONE (209)468 ID # <br /> P 0 BOX 2009, STOCKTON, CA 952 FF��((�� <br /> ERMIT EXPIRE 1 YEAR FROM DATE fag# <br /> (Complete in Triplicate) INV <br /> JI <br /> Application is hereby andC to Ban Joaquin County for a permit to construct and/or in Il,r f► <br /> application in evade in coapllance with San Joaquin County Ordinance Be. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services, <br /> li <br /> x Job Address UI - ,�Au4ti Gay Y•`41i,7 1/��.�_,/Lot Size/Acreages <br /> �(Owner i Ne �J Address r S. o*' 'P � –- _ PhonFt'�I3 J <br /> X Contractor 0fXyZ-- Address ( License No._ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 . OTHER ❑ Monitoring Well O <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial O Open Bolcom ❑ Manteca Die. of Well Excavation Dia. of Well Casing r�> <br /> (.I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications <br /> ZOO <br /> fl Public [-I Other Il Delta Depth of Grout Seal Type of Grout <br /> I I Inivarion _Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destfuction ❑ Well Diameter Sealing Material a Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION (No septic system Permiued it public sewer is <br /> vailable within 200 feet.) 'lam <br /> Inat7tlat ill serve: Residence— Commercial_ Other �_ –� <br /> Number of living units: Number of bedrooms <br /> Character of soil to ■depth of 3 leer: *ter table depth <br /> SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal 1 <br /> Distance to nearest: Well Foundah Property Line <br /> LEACHING LINE Ll No. 6 Len mss _ Total len ize <br /> FILTER BED ❑ ca to nearest: Well Foundation _ Property 1 <br /> SEEPAGE I I Depth Size — Number <br /> S LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 end regulations of the San Joaquin County <br /> Home owner or licensed agant',signature certifies the 10110wmg: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any parson in such manner as to become subject to workman's compensation law,of California."Contractor's hiring or subtrcontrscting signature <br /> certifies the following: "I Certify that In the performance of the work for which this permit is issued. I shell employ persons subpct to workman's componss <br /> tion lawn of California." <br /> The appN licant ,¢call for ran u rY i clions. Complete drawing o everyy rse side. <br /> xSigned r Title: �IA/[�11 .aJ--=w.,�—�L,Lr/r' Date: <br /> FOUR DEPARTMENT USE ONLY <br /> Application Accepted by -- ���= [n'�� Dare _ t9e <br /> Pit or Grout Inspection by Data Final Inspection by_ ' Dere <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services SRD000 8a�J <br /> Environmental Health Permlt/'services <br /> 445 N San Joaquin, P O Box 2009, Stan, CA 95201 <br /> FEEINAMOUNT DUE AAMMJOUNT REMITTED CCA SH REC EO BY DATE 7 PFR.MIITJ NO. <br /> . EN IX3-N111EV.t/ea <br /> En u_ie <br /> t _ <br />