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4 i '�l2 6 5 4 S 6 P. 02 <br /> _I <br /> ! .. APPLJ CATI ON FOR PERU I T � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SSRVICSS <br /> ENVIRONMENTAL RSALTH DIVISION <br /> P 0 BOX 2009, STOCSTONt CA 95201. 7 <br /> (208) 468-84*7 <br /> (Complete in Triplicate) <br /> Application in hereby made tO San J06Quiq County for a permit td construct and/or instal] the vork hcrciri descrit>ad. This <br /> ■pp]Acation is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the'Rulee and Aagulationa of San <br /> Joaquia County Public health Sere pee. <br />! L <br /> Job Address CItY ""`_� Lot Sfte/A^_reage _i <br /> "�Q11 _t <br /> L�E3� _ �� . i Add eee G LJJ111.�N•�Q <br /> qb <br /> Ownsr's Name j hLL� !'! _ Phone <br /> prl,n, 1 <br /> Cent+actor Address Q� ' OW� License Nc -Sh- T8 hone?V62311 <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Cr D DEy5TA49jTION 0 Out o service well <br /> PUMP INS1ALL.ATION 0 SYSTEM REPAIR L� � ` 1 ICICI _nnitoring Well L7 <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL. FLD. lJ PROP LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 171 industrial ❑ Open Bottom iJ Manteca Die. of Well GReavation 013, Of Wets Casing <br /> U Domestic/private O Gravel Pack C3 Trary Tyue of Casing Specifications A,, . <br /> ❑ Public �'- I'3 Other I 0 Dena Depth of Grout Seal ~` Type of Grout DeQft <br /> �Fm�►� <br /> z=' ITr+gation Approx. Depth C3 Eastern Suriitice Seal Installed by_...,; I ja df 4!!V1 Sr <br /> Repair Work Done U Type of Pump __- _-__ H,P. ' �. State Work Dona <br /> Well Destruction O Well Diameter Benita material t6 Depth <br /> Depth Piller Material i Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION❑ R5PAIR/ADDtTI0N L-1 DESTRUCTION M lNo sepire ,yStem,permirled it public atrwer fa <br /> evailabie within 200 feet.l <br /> Installation wItl serve! Residence Commercial_.__ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet; Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capaeity No. Compartments <br /> PKG. TREATMENT PLT.Cl Method of Disposal <br /> 'It <br /> Distance to nearest: Well Foundation Property Line <br /> EACMING LINE Ll No, 6 Length +7f lines Total length/sits_ <br /> FILTER BED 0 Distance I& nearest: Walt Foundation �„_,.., � Property Line t <br /> SEEPAGE PITS 11 Depth _ <br /> -Size _ Number <br /> UMPS L'I DiilancA to nearest: Well Foundation Property Line kA <br /> Y DISPOSAL PONDS O <br /> I hereby certify that I hove prepared this application'and that the work will be done in ecCorpance with Sen Joaquin e6unly ordinances, State laws, and <br /> rule, and ragufations of the San Joaquin county <br /> Moine owner or liCensed egani's signature certifies the following; "t certify that in the performance of the work for which this perrlvt is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'$ hiring or subcontracting signature <br /> certifies the following: "1 Certify that in the performance of Ilii work far which this permit it Issued, I shall employ persons subistt to workman's compensa- <br /> tion laws of California." <br /> tithW <br /> epplica Wei c1I all required inspections. Completo drawing 0n eve side. !l <br /> ✓J[1F + i <br /> geed tiNe: Pate: r <br /> 1 <br /> 2Z,�DPAIRTMINT E ONLY <br /> Application Accepted byData �I �r Area <br /> Pit or Grout Inspection by Date Final Intipection by Date <br /> Additional Comments: _ <br /> Appliceat - Retursr all aopiea tot SAH JOAQUIN COLthTY PUBLIC HEALTH BERVICEB <br /> EJfVIRONMENTAL REALTH DIVISION PERMIT/SERVICER � <br /> F. <br /> i 445 H SAN JOAQUIN, P 0 BOX 2000, STOCKTON, CA 06201FIE <br /> INF AMOVN7 OtJE AM04'NT ftEMrTTEO CASH CASH BY DATE pt:RM17'NQ. <br />