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Y w <br /> APPLICATION FOR: PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPiRES 1 YME FROM DATE ISSUED <br /> � <br /> (Complete in Triplicate) <br /> Application is hereby made to Sac Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made inc liance vith San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Josquin County Public He th 8 ices. , } <br /> Job Address116 City [/�[CJJ/ Lot Site/Acreage <br /> Address v Phone <br /> C t c _ddres <br /> hone r ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME I•] DESTRUCTION ❑ Out Of service Wen Well ❑ <br /> -PUMP INSTALLATION• SYSTEM REPAIR ❑ OTHER ❑ ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> $bmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br /> I'1 Public f] Other' _❑-Delta-���-�^-Depth-of-GrourSealT—�-"-" Type of Gr ut <br /> I I Irrigation —.Approx. ept 1 I ass rn ' Surface Seal Installed by ; <br /> Repair Work Done 0 Type of Pum H.P. , State Work_ <br /> Wel! Destruction © Well Dia t Sealing Mtateftal A Depth ? " <br /> m <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION t I DESTRUCTION I 1 INo septic system permitted it public sewer Is y <br /> _ available within 200 feet.l , <br /> Installation wdl serve: Residence— Commercial Other R <br /> Number of living units: Number of bedrooms <br /> Character of&ON to a depth of 3 feet: I a Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg P �'° Capacity No. Compartments <br /> PKG. TREATMENT PLT.Or <br /> Method of Disposal <br /> Distance fornearest:` Well `` Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> FILTER BED:, ±. ❑ Distance to nearest: Well Foundation Property Line <br /> f R i <br /> SEEPAGE-WITS"` '1 1-66 p'th i�te Number <br /> SUMPS LI Distance to nearest: Well Foundation .Propa'rty Line <br /> DISPOSAL PONDS ❑ —,.1 ' <br /> I hereby certify that I have prepared this application and that the work will be done in accordahce with Sah Joaquin county ordinances, state laws, and <br /> rules and regulations of the.San Joaquin County �-^- - -'-�j <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> 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 c mpensa- <br /> tion laws o ornla. ' <br /> The applic ` at call ired 100spoctions. Complete drawing on erse side <br /> r <br />` SigTi I Date: <br /> d�FOR DEPARTMENT USE ONLY / <br /> I Application Accepted by Date Are ` <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 <br /> f Environmental Health Permit/Servicers <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IFS AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATES PzERM/IT� 14D. <br /> EH 1}21 IREV.ri�si • r r.'`� �s�i © � � D ,� O 1� ✓—VS� <br /> EH t�•76 <br />