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APPLICATION FOR PER]-,.' <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> cu <br /> ENVIRONMENTAL HEALTH DIVISION IN/0 <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 O <br /> PERM T EXPIRES 1 YE FROM DATE ISSUM ' <br /> (Complete in Triplicate) <br /> Thi <br /> tall <br /> work <br /> in described. <br /> application is made incooupliance withuin SanCounty Joaquinor a County ordirmit tnancenstruct No. 549sando1862sand the Rules andeRegulations of San <br /> 6 <br /> Joaquin County Public Health Services. <br /> � City ��f=Let Size/Acreage <br /> J( Job Address <br /> s\ L/� fJ <br /> Owner's Name <br /> Address � • � �� Phone <br /> Contractor Address <br /> License No.� Phone <br /> ice well 0 <br /> YPE OF WELLlPUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCYION ❑ Out Monitoring well 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES --- <br /> DISPOSAL FLA. PROP. LINE <br /> FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE "TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing )-Z,C7 Industrial E) Open Bottom ❑ Manteca Dia. of Well Excavation, <br /> Cl Domestic/Private 0 Gravel Pack7 ❑ Tracy' Type of c / <br /> 11 Public (:1 Other- fl Delta Depth 61 I V lO p ( 3L-) F <br /> I I Irrigation —Approx. Depth I I Eastern Surface A <br /> Repair Work Done L1 Type of Pump H.P. <br /> Sealing Materia <br /> Well Destruction O Wall Diameter hiller Materia.] <br /> Depth <br /> ,war is � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION t I ¢- <br /> Installation will serve: Residence —. Commercial `� Other <br /> �] J <br /> i <br /> Number of G <br /> Character F"I <br /> Tft n M. N <br /> SEPTIC TAN r Typegl�Mfg <br /> PKG. TREATMEIPg"�1rnay have W�� O¢�,,,� <br /> p�f �r I . tsk6 -— Found, . <br /> wok be4it", <br /> LEACHING LINE by �-,NJTWV.'Leri k 1.0 <br /> _. t <br /> FILTER BED ❑ Distance to nearest. Well Founc <br /> SEEPAGE PITS I I Depth Size Number <br /> I <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL PONDS ❑ <br /> r that she work will be done in accordance with San Joaquin county ordinances, state Laws, and <br /> I hereby certify that I have prepared this application and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I she not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hifing or sub,contracting signature <br /> canifias 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 compentla- <br /> tion laws of California." <br /> The applicant m c II for all J c' ns. Complete drawing on reverse side. <br /> Signed r Title: , Date: <br /> R DEPARTMENT USE ONLY <br /> `••� Date 2 -� Area <br /> 9J J <br /> Application Accepted by 4...4 <br /> Pk or Grout Inspection by <br /> Date Final Inspection by Data <br /> '\ddhional Comments: <br /> Applicant - Return all Copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services �\ <br /> 445 N San Joaquin, p O Box 2009, Stkn, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> FEE AMOUNT Ou AMOUNT REMITTED CASH <br /> 7 y, °� S27b <br />