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APPLICATION FOR PERMIT <br /> ix SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E HAZELTON AVE. , PHONE (209)468-3420 r <br /> = P O BOX 2009, STOCKTON, CA 95201 h <br /> ¢ EXPIRES 1 YE R FROM DA h <br /> (Complete in'Triplicate) <br /> scribe <br /> Application is hereby, made,to li San vithuSaariJoaquinfor <br /> county ordinanceconstruct <br /> No, 549and/or <br /> 1862install <br /> and thethe <br /> Rules andherein <br /> Regulationsdof Sans <br /> application is made in compliance i q <br /> Joaquin County& c 3ervicea. f <br /> �I <br /> [� City eAlcl— Lot 512e/Acreage <br /> Job Address t q �A4�s I <br /> Phone <br /> Address _�a - ��..-��•t-.�--_�'_.�'.�.,.. -�- , <br /> Owner's Name _.., .m_..- •.......----- -- '-.�� <br /> "'Cont7actpr�_.`v-�I �-z• <br /> L NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well CI <br /> TYPE OF WELL/PUMP: OTHER ❑ Monitoring Well 17 <br /> PUMP INSTALLATION ❑ 5YSTEM REPAIR ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES PlT5/SUMPS <br /> FOUNDATION AGRICULTURE WELL t OTHER WELL <br /> INTENDED USE_ , T-YPE OF}WELL PROBLEM AREA CONSTRUCTION.'SPECIFICATIONS r <br /> fl Industrial ,` t ❑ Open Bottom ❑ Manteca Dia. of Well Excal ation <br /> Dia. of WeII,Casing <br /> Specifications <br /> C1 Domestic/Private =! D Gravel Pack ❑ Tracy Type of Casing Type of-G ui <br /> i"1 Public r f 1-1 Other (-1 Delta Depth of Grout Seal <br /> I I Irrigation rR F �.Appiox. Depth l I Eastern Surface Seal installed by , <br /> H P State Work Done i <br /> Repair Work Done U- Type of Pump Sealing Material & Depth xk, <br /> Well Destruction ❑ iWell Diameter r Filler Material b Depth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION-k�l^rDESTRUGTION i 1 aNaiiabperc system within 200 feet if public sewer is <br /> if <br /> �. <br /> installation will serve:. Residence Commercial Other <br /> I Number cf,living units: �_ Number of bedrooms E <br /> Water table depth <br /> � <br /> Character of soil to a depth of 3 feel,: � � <br /> SEPTIC TANK Irl Type/Mig — Capacity No. Compartmentsrj Wil' * 'Me hod of Disposal <br /> fff PKG. TREATMENT PLT. ❑ � e <br /> ' `= <br /> Distance to nearest: well Foundation — Property Line <br /> i r <br /> LEACHING LINE LI No. & Length of lines 4' � r T Total lengthlsize O i <br /> FILTER BED CI Distance.to nearest: w6w, / < Fou'ridation \Property Line <br /> r SEEPAGE PITS 11 Depth I —Size f" Nu`rnber <br /> i SUMPS Distancelto nearest: WellL_ Fountlstion Property Line <br /> DISPOSAL PONDS Ca 'r' <br /> I hereby certify that I have prepared this application-and-that the work will be-d.a in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County `, "= -W- h6 <br /> r <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 lawsiof-California-" Contracir6l`3 iiring ar usus b•contracting signature <br /> certifies the following: "I certify that in t e performance of the Work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." a _ �. IN <br /> The applicant must call for II re ired ins tions Complete drawing on reverse side. <br /> Signed x <br /> r sTitia: Date: <br /> '� <br /> i <br /> -DEPAWMENT USE ONLY i <br /> as <br /> Application Accepted by Y <br /> Date <br /> Pit or Grout Inspection by Date, Final Inspection by _ <br /> Date <br /> / . <br /> � A r <br /> Additional Comments: ' <br /> I Applicant - Return all copies tol: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> i <br /> nFEE AMOUNT DUE I' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'-NO, <br /> EH 17,241AEY.1lr551 <br /> EH 44-20 f <br />