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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ND W <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)468-3420 N D Q -C_ - <br /> P O BOX 2009, STOCKTON, CA 95201 P I <br />� PERbdIT ESPY RES ]. Y FR ld D ,TE I SSIIED <br /> (Complete in Triplicate) <br /> for a permit to construct and/or install the work herein described. This <br /> Application is hereby made to San:Joaquin County <br /> Ordinance No. 5u9 and 1862 and the Rules and Regulations of San <br /> application is made in cee>pliancelvith San Joaquin County <br /> J <br /> in Count <br /> u Y Public Health Serylee . i 1 <br /> // �• City Lot Size/Acreage <br /> Kob Address <br /> It " "` <br /> C� <br /> (01 <br /> Phonener's Name <br /> ` ? r Phone <br /> k Contractor �" <br /> f- 1�- -14ddress � License-No— <br /> .NEW WELL 13WELL REPLACEMENT ❑ DESTRUCTION Out of Service well O <br /> PE Of WELLIPUMP: OTHER ❑ Monitoring well ❑ <br /> PUMP IfJSFALLATlON ❑ J`*.-.: _ SYSTEM REPAIR El <br /> hSEWER LINES. -- DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK _ <br /> FOUNDATION ; --AGRICULTURE WELL OTHER WELL � PITS/SUMPS ._ <br /> y.. '1 <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA COf�STRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> CI Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation t Specifications <br /> N Domestic/Private ❑ Gravel Pack L7 Tracy ! Typ of Casing_ <br /> '�"Depih of Grout Seal _ Type of Grout <br /> VI Public C:1 Other n Datta , <br /> I I Irrigation ApprAx. Depth I I Eastern Surface Seal Installed by r <br /> U T of Pump H.P State Work Dons <br /> Repair Work Dona Ype ' <br /> ^�:"-Se`aling WteFiiil;"i`Depth <br /> Well Destruction O Well Diameter Filler Nst <br /> Depth *7 <br /> I I <br /> Sys <br /> t )i1public sewer is <br /> TYPE OF SEPTIC WORK. NEW INSTALLATION 11' REPAiR1ADDITlO I i'D vasa Is within feet: <br /> Installation will serve: Residence Commercial_ Other PeFmit may have expired without <br /> I Number of living units: Number of bedrooms work being completer' gr Uged <br /> l <br /> Character of$00 to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg J�-- <br /> r <br /> PKG. TREATMENT PLT. Method of Disposal`" <br /> (D + <br /> I <br /> Distance to nearest: well Foundation Property Line � <br /> € -LEACHING LINE 0 No. m Length of linea Total Iengthlsize <br /> FILTER BED 0 Distance to nearest:''"' W6I1 �^' —Ffoundation- - = Property Line <br /> SEEPAGE PITS I I Depth I Size Number <br /> SUMPS Li Distslu to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ s <br /> I he certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> rules and regulations of the San Joaquin-County. _ _ 'wok which permit <br /> 'Homs owner or licensed agent's signature ceitifin$the following: ' cent hat in h he of the work for which this permit is issued, l shah not <br /> employ any parson in such manner as to become subject to workman's compensation_lawe of California.'-Contractor's.hiring-or.sub-contracting signature <br /> certifies the"foAowrnp: `I cirtily that in iiia performance of the work for which this permit is issued, I shall employ persons subject to workman's eomps'nsa <br /> tion laws,of California." <br /> ' <br /> ZO ,2Ci =metedrawii,on reverse side.�The applicn or l - <br /> Title: — Date: ! J <br /> tuned l <br /> FOli DEPARTf( NT USE ONCY' <br /> Application Accepted by <br /> � Data �.�— '� Area ©2- <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ! <br /> r <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> I <br /> 445-N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ��Z <br /> Z[jT DUE AMOUNT REMITTED CASH RECEIVED BY OAT PERMIT'NO. <br /> a�� I <br /> EH 1&-7a <br />