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r APPLICATION FOR PERMIT <br />�1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />06 .1� <br />`f ENVIRONMENTAL HEALTH DIVISION <br />tom- ®05 P 0 BOX 2009t STOCKTON, CA 95201 20-366b -O <br />(209) 468-3447 <br />PE_�4IT E IR s� YTAR �' ISSU <br />(Complete is Triplicate) <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br />application is made in compliance with San Joaquin County Ordinance No. and 1$62 and the Rules said Regulations of San <br />Joaquin County Public Health Services. <br />Job Address r 1,, '{ �" /f2 <br />" s' "� �� ' City Lot Size/Acreage <br />Owner's Name 1 " Address Phone <br />ContractorAddress License No. Sf 2 � ? Phone 2.L j` <br />LA&TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service well ❑ <br />PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER 16"( Z4h Well C7 <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. f <br />FOUNDATION AGRICULTURE WELL OTHER WELL _.--- <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tt 01&%j <br />n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation <br />U Domestic/ Private O Gravel Pack O Tracy Type of Ca n $D► <br />M Public Cl Other CO Delta Depth of IC 3V T t t <br />G Irtigation w Approx. Depth 0 Eastern y l ' V CC <br />Repair Work Done (3 Type of Pump H. P. `"p t i <br />Wall Destruction O Well Diameter Sealing Material i Depth , <br />Depth Filler Material i Depth f 6W <br />TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION CI DESTRUCTION Cl INo septic system permitte if pubile Rawer is <br />available within 200 feet.) <br />Installation will serve: Residence _ Commercial ® Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK O Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT. CI Method of Disposal . <br />Distance to nearest: Well Foundation Property Line <br />LEACHING LINE 0 No. 8 Length of lines Total length/size <br />FILTER BED n Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS 1 I Depth Size Number <br />SUMPS LI Distance to nearest: Well Foundation Property Line <br />DISPOSAL PONDS O <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and <br />rules and regulations of the San Joaquin 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, f shall not <br />employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub -contracting signature <br />certifies 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 compensa- <br />tion Iaws of Cali ornia.'° <br />The applicant st call forrequirl i pections. Complete drawing 0"PerAMide. <br />Signed Title' " Date: ( Z� <br />FOR DEPARTMENT USE ONLY <br />9 <br />Application Accepted by ce,at � r ®�' �"' Area ._1 <br />Pit or Grout Inspection by Date Final Inspection by We Data ®' %2 <br />Additional Comments: aAA. <br />Applicant — Return acopies to:v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES &�` <br />ll <br />ENVIRONMENTAL HEALTH DIVISION PERMIT/SERVICES rti <br />448 N SAN JOAQUIN, P 0009, STOCKTON, CA 95 01 <br />° EH 13.26 TREY. r r as <br />EN ,6.26 <br />r4 <br />