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l <br /> APPLI"CATIONI 'tF'OR PERMIT - k <br /> SAN QAQUIN,, COUN <br /> TY PUBLIC BEAT.,TH SE�VIC�S <br /> ENVIRON"MZNTAL HEALTH DIVISION <br /> P O BOX 2009, STOCKTON$ CA 95201. <br /> a (209) 468-34' 47 . , <br /> PROM <br /> R , a <br /> :ACompleter in TripliciLte) <br /> Application is hereby meds to gas Joaquin County for a permit to,conetruct and/or lnatall the work herein described. This J <br /> application Is made in ace with Sea Joaquin County Ordinance <br /> Joaqula•County Public Heealthlth 3oServices. No. 549 and 1862 and the Rulea.aad Regulations of San <br /> Job Address gPnl t 43 -2(ao-08-o r <br /> --7— Ci[y TQ Lot Size/Acreage [i <br /> Owner's Name AJ Address15G�SFiAuJ Ry STaG� <br /> .. Phone G-z <br /> Conte ac tot.Seet' reu I t-;XDILOR _Address ,. <br /> TYPE OF WELL/PUMP: License No: � 2Co Phone ~-871 <br /> NEW WELL ❑ WELL REPLACEMENT" (� DESTRUCTION ❑ Out or Service well ❑ <br /> PUMP INSTALLATION ❑ ''" _SYSTEM REPAIR ❑ Monitorin "Vells <br /> DISTANCE 70 NEAREST: SEPTIC 'TANK 2�� ;L` OTHER p � 8 <br /> '•' SEWER LINES DISPOSAL FLD. ff14 PROP, LINE <br /> FOUNDATION 7.0, __i' AGRICULTURE WELL -Irl 'OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM'AREA CONSTRUCTION SPECIFIG"ATIONS <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r+' <br /> !i4 <br /> Domestic/Private : ` Dia. of Well Casing Q- - <br /> (Other Pack ❑ Tracy Type of Casing l7 �C l f O <br /> Public � Specilications �} <br /> is Other _❑ Delta 'Depth of Grout Seal F_ r <br /> CJ Inigalion °' Type of Grout C/wr <br /> Approa• Depth ❑ Eastern Surface So-1 Installed by Q01v !^,_7-&f2- <br /> Repair <br /> Work Done U Type of Pump H.P. a <br /> Slate-Work Done •�- <br /> Weil Destruction ❑ Well Diameter 'I Scaling Material'i. Depth \ 1� <br /> Depih Filler Material t Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION ❑ (NO saplic system permitted if public sewer is <br /> available within 200 feet.) <br /> InatallatiOn will serve: Residence , Commercial ',Other <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: s <br /> SEPTIC TANK ❑ Type%MfQ Water table depth <br /> ��� <br /> PKG. TREATMENT PLT.❑ Capacity_ No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE U No. & Length of lines <br /> Total lsngth/size <br /> FILTER BEO ❑ Distance to nosiest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Sire <br /> ;SUMPS _ - Number " <br /> L] 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,accoroance with San Joaquin county ordinances, state laws• and <br /> rule+ and regulations of the San Joaquin county ? <br /> Home owner or licensed agent's signature certifies the following: "I Certify thal in the perlorrTmance of rho work for which this permit ii <br /> employ any person in such manner as 10 become aWbjaCt tossued• I Shell not <br /> "workman's compensation laws of California." Contractor's hiring or subs•contrecting signature <br /> certifies the following: "I certify that in the performance of the work for which IN parm;t is issued, I shall employ tion taws of California." P v Persons subject to workman's compensa- <br /> The applicant mu ca f r all r uire inspections. Complete drawing on reverse side. <br /> 3 " ' <br /> Signed <br /> Title: Date: L. <br /> � . <br /> DEPARTMENT USE ONLY <br /> Application Accepted by" <br /> .09 <br /> Data A?aa <br /> Pit or Grout Inspection by Me- • ()site Final Inspection by <br /> S Data <br /> Additlonaf Comments: a <br /> Applicant • Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 31 �Q/0 /"�J <br /> FXVIRONMENTAL HEALTH DIVISION PERVIT/SERVICES <br /> 443 N SAH JOAQUIN, P 0 HOX:2009, STUCXTON, CA 95201 <br /> FEE AMOUNT DVE AMOVNT REMITTED CK ' <br /> INFO CASH RECEIVED By DATE PEAM11"NO. <br />" ck I3•21[REV. or <br />