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APPLICATTQN FOR PIsItMI <br /> u j <br /> f SAN JOAQUIN COUNTY PUBLIC HEALTH`I�SERVICES <br /> -"" ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, IjCA 95201 <br /> PERMIT MIRES 1 YRAR MOM '{D TESU <br /> (Complete in Triplicate)] <br /> l 4 <br /> i Application is hereby made,to Saa Joaquin County for a permit to construct `a.nd/or�install the work herein described. This <br /> application is made in comilance with San Joaquin County Ordinance No. 549.' and 1862 and the Rules and Regulations of San <br /> j Joaquin County Public Health Services. p <br /> y�� f <br />+ Job Address n Lot Size/Acreage <br /> Owner's Name far7 lo- e14 R- <br /> Ph a � <br /> Contfacto L �r� is ddress „" <br /> A1/k7 /"'�icen'sa (P0U <br /> TYPE OF WELL/PUMP: WEW WELL ❑ WELL REPLACEMENT ❑? if DESTRUCTION ❑ t of Service Well ❑ <br />+ Put, <br /> liel]S� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR n. jh OTHER O 3J <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. UNE <br /> i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA 1�OM jjj <br /> D Industrial C1 Open Bottom 0 Manteca Dia- of Well Excavation —IE Dia. of Well Casing <br /> [l Domestic/Private kGravel Pack ❑ Tracy Type of Casing_ /I p VIC_ Specifications <br /> €'l Public 171 Other Cl Delta Depth of Grout Sea! Type of Grout <br /> I € Irrigation —Approx. Depth I 1 Eastern Surface Soul Installed CD. <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material i Depth I l', <br /> Depth biller Material 1, Depth �j. • V`� r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> e available within 200 feet.) O <br /> installation will se Residence ommercial_._,_ Other <br /> E Number of living unit mber of bedrooms <br /> Character of sail to a of 3 feet: j Water table depth <br /> SEPTIC TANK O T Mfg Capacity Jj No. Compartments L• <br /> F PKG. TREATM PLT.Cl Method of Disposal <br /> Distance to nearest: Well Foundation 1j Prrty Line t <br /> LEACHING LINE No. gth of lines Total length/size m <br /> 4 <br /> FILTER BED tams to nearest: Well Foundation Property Line <br /> 4 I! <br /> SEEPAGE PITS Depth Size Nlumber rn <br /> SUMPS scants to nearest: Well Foundation Property Lino <br /> j DISPOSAL PONDS ❑ j <br /> I hereby certify that I have prepared this anon and that the work will be done in accordance with San Joaquin county ordinances, state laws, and f <br /> rules and regulations of the San Joaquin Count <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 i <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring of subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I she employ persons subject to workman's componsa- <br /> tion Iowa of California." <br /> The applicant must call or all required in tions. Complete drawing on reverse side. k <br /> Signed X AA Title: - Cxo Date: <br /> FOR DEPARTMENT USE ONLY. <br /> 11 <br /> � I <br /> • <br /> Application Accepted by Date � '� Are 0a • { <br /> g <br /> Pit or Grout Inspection by Date Final Inspection � Date <br /> Additional Comments: 3q 1j1tV12ti �1� <br /> � ��Applicant - Return all copies to: San Joaquin County Public Health Services Fx <br /> Environmental Health Permit/Services <br /> 445 N Sao Joaquin, P O Boa 2009, Stkn, CA 95201 <br /> INFO <br /> EEE AMOUNT OVE AMOUNT REMITTED CASH CK RECEIVED BY ,�� DATE;'11 PERM �NO. <br /> • <br /> EH 11.28 <br /> OC EH 13241#EV-+Iasi � 1 7 ■ <br /> I <br />