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APPLICATION FOR PFMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICS3 <br /> I ENVIRClNHENT AL HEALTH DIVISION <br /> 1801 B_ NAZET AVE., PHONE (209)46$-3420 <br /> 1 P O BOX 2009, STOCKTON, CA '95201 <br /> j p IT WIRAO 1 YEAR IRON DATE ISS( i <br /> (Complete in Triplicate) <br /> Airplieation is hereby made,to Sea Joaquin County far a permit to construct a=Vor ivaimll the trprk herein described. This <br /> application is made in ecmtpifwnce with San Joaquin County Ordinance No. 549 turd 1862 and the Rules and Regulations ar San <br /> Joaquin County Public Health Services. <br /> Job Address City Arlo <br /> Siz / <br /> eage <br /> 04+1 <br /> �w � / <br /> Owner's Name AddressPhOne <br /> .Contractor Address License No.41T -Phone <br /> ] <br /> TYPE OF WELL/PUMP:. NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service ell i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER d Koaitoring Well C3 <br /> DISTANCE TO NEAREST: SEPTIC TANK: - SEWER LINES DISPOSAL FLO. PROP. LINE -•- <br /> NDATION AGRICULTURE WELL OTHER WELL PITWSUMPS , <br /> INTENDED USE TYPE OF WELL PRO NST�UCTIO SPE ! ATION - ' <br /> 0 industrial 0 Open Bottom Q Manteca Dia.-c on Dia.of W.0Casing J, <br /> Cl Domestic/private 0 Grevat Pack 0 Tracy Type of Casing � Specifieaiioos <br /> Il Public (7Other Cl pelta Oapth of Grout Seal } Type of Gr ` <br /> 1 I Irfigatton Approrr. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Oone 0. Type of Pump H.P. State Work Dime <br /> Well Destruction , 0 Well Diameter f tteslitlg Itsteriai i Depth <br /> -- Piller 1laterial 6 Depth t s <br /> Depth t-- -- V► <br /> TYPE OF SEPTIC WORK: HEW INSTALRATtON 1 1 REPAIRIADDITION DESTRUCTION 1 1 fNo septic system permitted it public sewer is ; <br /> I available within 200 feet.) <br /> 1 installation will serve: Residence AL C nkmetclal other <br /> Number of living units:--I— Number of tiedroo <br /> Cheracter'of trop to a depth of 3 fest: I A&%'_ L•i Waive tome depth <br /> SEPTIC TANK Q Type/Mfg•I I j Capacity —I 4O. rtments <br /> l PKG. TREATMENT.PLT.❑ .1 . f Method of Dtsposai <br /> Distance to nearest: Well Foundation ''rroperty Line <br /> LEACHING LINE p((Na. a Length of imes / 4 `'3 Totaa.ierMth/size <br /> R r� <br /> FILTER BED Or Distance to nearest; Well IroundatioA;' -- -- 'ropsAy Line ,SJ <br /> SEEPAGE PITS Depth s ` Sias ` r Number.4 y , <br /> SUMPSt l Distance torest: Went A :2 Found)iioif� Property Line, 9 I <br /> DISPOSAL PONDS Q f ' '- '. <br /> i hereby certify that 1 he"prepared this appilcation and that the work will be donein accordance with.S4A 4aaquin county ordinances,state laws,and <br /> rules and regulations of the San JoeWIn Cotmty "ry #i i <br /> Home owner or licensed agent's signetwe aNt fees the following:"1 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 becoms subject to workman's compensation laws of Catiforttis,"jpg6tractoes ahidn8 w tub contracting signature � <br /> certifies the following:"I cantly that in ttts performance of the work for which;hts-pern-dr-wissus .tdlhatt tarirpiay`�araanssubjeel to Workman's Compensa- <br /> tion taws of Caftrals." I ! �'-�. A <br /> Ttre applicant t call for all rei uirad pact?C&WO-ete drawing onsavea� $I <br /> Signed + Tile: Date: <br /> 'MOOR DEPARTMENT USE ONLY <br /> Application Accepted by t Data i Area <br /> Pit or Grout Inspection by Date FtnW Inspection by. Date f f sd - O <br /> Additional Comments: n <br /> - s <br /> Applicant - Return all copies to: Ban Joaquin County Pub]Ae Health ' <br /> -Services, luvirot>mastal Health Permit/Servioes { <br /> IL601 E. Hatelton Ave.. P 0 Box 8009. Stockton, CA 95201 <br /> INFO <br /> EEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> `9+hsit�salaEv.rrny <br />