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4 / R" <br /> APPLICATION FOR PWW I T T ! s <br /> SAN JOAQUIN COUN'T'Y PUBLIC EEALTH SERVICTS- <br /> ENVI RONVENTAL _REALTH D'I V I SI ON <br /> } P O BOX 2009, STOCKTON., CA 95201 <br /> (209) 468-3447 <br /> PERMIT BUIRE65 1 YEAR P- - DA 35SUSD i <br /> (Complete is Triplicate) , <br /> I Application Is heiriVy made to San Joaquin County for a permit to construct and/or-install the work herein described. .This <br /> application is made in comtpliantte vith Ban Joaquin County Ordinance No. 549 and 1862,and the Rules and Regulations of San <br /> Joaquin County Public Health Services. ,_y <br /> ` Job Address _ I r Z[• ,,,.. '- fi'Qn 4ff City Lot Size/Acreage C <br /> Phone <br /> -�Centrad -G <br /> os, �{- " rS Address _ L ► e do <o72 Phone 7ys~may <br /> TYPE OF WELL"/PUMP; NEW WELL WEL REPLACEMENT 0 _ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION YSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ w <br /> DISTANCE TO NEAREST: SEPTIC TANK �Lb SEWER LIQ S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 3C` OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAt10NS <br /> C1 Indu ia1 ❑ Open Bottom ❑ Manteca Die. of Weil Excavation Dia. of WeII.Csaing ` <br /> ameetic/Privets; 1 q—Gravel Pack ❑ Tracy Type oFCaS' ll� <br /> rung pecifications <br /> I -M PtilSlic ` C1 Other"-- 0 Delta Depth of Grout Seal Type of Grout Ci II S <br /> CJ IrriUation _.ApproK• Q�p{h . C�asmern ,race Seul Insmallsd by <br /> Repair Work Dorie U Type of Pump H.P. Stetrr Work Done <br /> Well Destruction '- 0 Well Diameter Sealing-Material i Depth <br /> Biller Material ✓V Depth s <br /> Depth .' <br /> TYPZ OF SEPTIC WORK: NEW INSTAt:LATION D REPAIRIADDITION 0 DESTRUCTION Ci tNo septic system permitted if public sewer is+ i <br /> _ e a <br /> availblwithin 200 lest.) <br /> `y f <br /> Instslletion will•itervs: Residence.,.,...., Commercial— Other -_� °�~ a-+�� �. - r '_ •rf y,�. <br /> Number of living units: Number of bedrooms <br /> - <br /> + Character of soil to a depth of 3 feet: - a Water table depth <br /> 11tt SEPTIC TANK p Type/Mira '"� . { Capacity- No. Compartments,,- <br /> PKG. TREATMENT PLT.❑-, Mdlhod of Disposal f_ <br /> Dlslihce to nearest: Well Foundation Property Line r <br /> { LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BEd 0 Distance to nearest: Well �Foundation Properly Line <br /> SEEPAGE PITS - 11 Depth Size Number <br /> SUMPS Ll,.Vistenca4o nearest: Well Foundation Property Line <br /> ` <br /> ." DISPOSAL PONDS .0 <br /> f I hereby certity, hat I have p4pared this application and that the work'wiil be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Josquin County ' <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 shell not <br /> employ any person in such manner as lo,become subject to workman's compensation laws of California,"Contractor's hiring or sub-contracting signature <br /> certifies the following: '9 certify that in tN performence of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> r The applic nt call inspections, Complete drawin ferse side. <br /> Signed Title' AQ' a <br /> Oats. <br /> { .I FOR DEPARTMENT USE ONLY <br /> } XApplicatkon Accepted by Date Area �� <br /> ■; <br /> Pit or Grout Inspection by Date Final Inspection by te at <br /> ? <br /> Additional Comments: �-� <br /> f AppllCaat - Remora all copies to: ':,SAN JOAQUIN COUNTY PUBLIC HBALTH SERVICES y <br /> } ENVIRONMENTAL HEALTH DIVISION PERLIT/SERVICES Yom. <br /> 445 N SAN JOAQUIN, P 0 SOK 2000, STOCKTON, CA 95201 <br /> FEE `AMOVNT DUE AMO NT nEMiTTED CA,51H RECEIVED By DATE PERMIT'NO. <br /> I. EM'i>NIREV.If"srrl:VV'*c�p� PO <br /> EM tC�a Y'1L/ $ 1 <br />