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`r` APPL I CAT I OH FOR PERM I T <br /> . <br /> , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br />'k <br /> PERMIT EXPIRES X YEAR FROM DATE <br /> (Complete in Triplicate) <br /> Application is hereby made to Sas Joaquin county for a permit to construct and/or install the work herein described. This <br /> application is tasde in coWliance with San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> Lot Size/Acreage c/ City <br /> Job Address ;• '""� �. <br /> Owner's Name <br /> Address Phone <br /> dress f erase No. Phon <br /> Contractorq�✓ <br /> j TYPE OF ELLlPUMP: NEW W LL ❑ WELL REPLACEMENT [-] DESTRUCTION t 7f Service 11 0 <br /> �n ging Well C) <br /> PUMP INSTALLATION ❑� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEA T: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. L <br /> MPS <br /> I NDATION AGRICULTURE WELL OTHER WELL PITS U <br /> INTENDED USE TYPE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial ❑ Open Botto _D�Manteca Dia: of Well Excavation is. of Well Casing <br /> T .6fCasing Specifications [� <br /> Ca Domestic/Private ❑ Gravel Pdck '� ❑•Tracy �Type g— Type of Grout <br /> I'1 Public la Other Delta Depth af'Grout Seal <br /> l I Irrigation —Approx. Depth I I E am Surface Seri Installed by (n <br /> Repair Work Done U Type of Pump P. Sta ork Dvne <br /> j Ing Material i Depth <br /> Wall Destruction ❑ Well Diameter <br /> l Fill Material <br /> Depth i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDI N I I DES UCTION (No septicailable system <br /> m fee tjed if public sewer is <br /> f <br /> installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms <br /> Character of Will to a depth of 3 feet: rWater table depth <br /> I SEPTIC TANK ❑ Type/Mfg (°ti 4 capacity, I .fi No. Compartments <br /> PKG. TREATMENT PLT.❑ 4 .. ' Method of Disposal <br /> Distance to nearest: !I Foundation roperty Line <br /> LEACHING LINE ❑ No. & Length of Ii s Total length/ • e <br /> FILTER BED ❑ Distance to est. Well Foundation Property 'na <br /> SEEPAGE PITS i I Depth Size Number <br /> i SUMPS Ll D' ante to nearest: Well Foundation Property Line <br /> k DISPOSAL PONDS ❑ <br /> I hereby certify that I e prepared this application and that the work will be done in accordance with San Joaquin county rdinances, elate laws, and <br /> rules and HowcenZ <br /> the San Joaquin County <br /> Home owagent's signature certifies the following: "i certify that in the performance of the work for which this pe it is issued, I shall not <br /> ampby such manner as to become subject to workman's compensation laws of California." Contractor's hiring or au ontracting 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 tow man':compansa <br /> F <br /> tion laws of California." <br /> The applicant a ar req ired inspections Complete drawing on erse side. <br /> Signed Title: . , _ Date: <br /> DEPARTMENT USE ONLY <br /> � Application Accepted by Date Arsa �•�° <br /> uzn <br /> Pit or Grout inspection by Date <br /> Final Inspection by Date <br /> i <br /> { Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County'Public Health. Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK ECEIVE0 BY DATE PERMIT*NO. <br /> INfO +��j / <br /> EN`a�<24 IAEV.gins) ,�� _ 7 fn . <br /> EM 4.26 "ff" LL/J <br />