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r L <br /> APPLICATION FOR PFRId I T hh � <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION. <br /> i P O BOX 2009, STOCKTON, CA 95201 <br /> f (209) 468-3447 <br /> Y R PRQN DATE ISSUED <br /> a (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 nd 1862 and the Rules and Regulations of San <br /> Joaquin County Pablic,Hiealth Services <br /> Job Address v `' , Cily Lot Siie/Acreage <br /> Owner's NaAddress P�° <br /> rry�``�� <br /> License N PhlContAddresAf6 <br /> 3�lactp <br /> I <br /> TYPE OF.WELL/PUMP: NEW WELL ❑ � WELLREPLACEMENT n DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK !a"' —S-EWER-ONES"°-- "A DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE f TYPE OF WELL PROBLEM•AREA`-CONSTRUCTION SPECIFICATIONS <br /> d 15- <br /> ustrial v ❑ Open Bottom 7-❑ Manteca Did of Well Excavation Dia. of Well Casing <br /> mestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specification�(Do <br /> ublic i'1 Other Y ;�❑ Della Depth of Grout Seal Type of Grout Q <br /> Ml Irrigation Approx. Dept - ❑ astern ace Seoul,I tailed by V <br /> ` Repair Work Done Type of Pump H.P. _ S to Work Done <br /> # Well Destruction O Well Diameter Sealing ]dsterial i Depth ,�{,n.PV <br /> c <br /> Depth Filler ilaterisl i Depth a <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION 0 REPAIR/ADDITION Cl DESTRUCTION Li (No septic system permitted if public sewer is <br /> available within 200 feet,) ` <br /> e Installation will serve: Residence Commercial Other. <br /> Number of living units. Number of bedrooms <br /> Character of toil to a depth of 3 feet: t # Water table depth (� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compaents <br /> ' PKG. TREATMENT PLT. ❑ .r_ rtmMethod of Disposal <br /> Distance to nearest:- Well — Foundation Pr pa y Line <br /> LEACHING LINE Cl No. & Length-of lines '* ' -° Total length/size <br /> FILTER BED ❑ Distance to nearest: Wel " Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 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 and regulations of the San Joaquin County *— <br /> Home owner or licensed agent's signature certifies the following "I certify that in the perlormance of the work for which this permit is issued, I shall not,, <br /> f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> G The applicant st call for I required in":ctio s, mplete drawing on reverse sidV 12 <br /> t <br /> Signed Title: —, A�:_11`& Date: <br /> 01 <br /> Rn <br /> USE ONLY I <br /> 4 Application Accepted byADate _T ? _ Area <br /> Pit or Grout Inspection by Date Final Inspection by T 2- <br /> Additional Comments: <br /> Applicant - Return all copies to: SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES <br /> 445 N SAN JOAQUIN, P O BOX 2009, STOCKTON, CA 95201 <br /> FEE AMOUNT DU9 AMOUNT REMrTTED CK # RECEIVED BY DATE Piinma,NO. <br /> FO CASH <br /> z <br /> . Eli t].I,IREV.,,MSi �Q� / d " <br /> EH t4•2e <br />