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f APPLICATION FOR PERMIT k€ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Now <br /> �1 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> /y 1 P O BOX 2009, ST OCKTON, CA 95201 N <br /> 0 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in 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. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. 4 <br /> �r\oh Address <br /> . / C�f �e r Cit Lot Size/Acreage <br /> Lontractor <br /> Name Vt �Xf IA Address �» r �-- Phone <br /> CA <br /> Address License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> r <br /> N DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> �,C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'i Public Cl Other f1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrivation t _ Approx. Depth I I Eastern Surface Seel Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ ►' <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> I Depth Filler Material & Depth 1 1< <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTIO 1 INo septic system permitted it public sewer 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: ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> j Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I•1 Depth Sire Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, 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, l 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 laws of California " <br /> N?"10 applica all for quired in ctions. Complete drawing on r verse side. <br /> �+/y\CC' r1 <br /> f igned Title: Date: <br /> F R D RTMENT USE ONLY <br /> t � <br /> r Application Accepted by Date Area <br /> Pit or Grout Inspection by ( / Date ! Final Inspection by J Date <br /> Additional Comments: �G_ 11�9� ]/��1 _f�s•---�c -c l .Sdt?T -fly tel- S i7C�2-��Sf?Tllil�G'7_ �tevZ _ <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, ftvironmental Health Permit/Servicesf� <br /> 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 J ` <br /> AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY DATE PERMIT N0. <br /> I <br /> + EH 13-241REV.»x5) 1 � Q L, <br /> EH 1426 <br />