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APPLICATION FOR PERM I T `C`---�.._.- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> EX! <br /> RES 1 YEAR FROM DATE'Ll 0 <br /> ED <br /> (Complete in Triplicate) <br /> 1 <br /> v 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. 5149 and 1662 and the Rules and Regulations of San <br /> Joaquin county Public Health Services. <br /> Lot Size/Acreage <br /> Job Address pw� 01 4M <br /> Address �-� <br /> Owner's Name dE <br /> �0��/�2 — Phone <br /> JQ Address41,V "'license Na, (�� Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL 5 WELL REPLACEMENT I l DESTRUCTION 1_l Out of Service Well <br /> t OTHER C] Monitoring Well L7 <br /> } PUMP INSTALLATION <br /> SYSTEM DISPOSAL FLD! '� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , - <br /> _ _ _ _FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED US£ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4 ,. <br /> Dia. of Well Casing <br /> n Industrial O Open Bottom © Manteca Dia. of Well Excavation ,cjVt7 /Avrs �3O <br /> 1 1.Gravel Pack u�C7 Tracy Type of Casing Specific uo <br /> FDomestic/Private <br /> i't Public [.1 Other ;=_.n Dena Depth of Grout Sea1� �i Type of Grout <br /> I Irrigation __.Apprax. Dep t. Eastern. Surface Seal Installed by fi <br /> Repair Work Done 0 .Type of Pump H.P. <br /> State Work Done <br /> Well Destruction D Well Diameter <br /> Sealing Material & Depth <br /> i, , Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I- REPAIRIADDITION l I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet,l <br /> Ins allation will server -Residence Commercial_ Other - <br /> �� N mbar of living units: Number of bedrooms <br /> erecter of soil to a depth of 3 feet: Water table depth <br /> S P71 TANK. © "Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. CL „ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LI No. & Length of lines . Total length/size <br /> M FILTER BED CI Distance to nearest. Well Foundation Property Line <br /> k SEEPAGE PITS I I Depth Size Number / <br /> I <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 will be done ih 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, I 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 /> i tion laws of California." <br /> The applicanlpuW ca for I required inspections. Complete drawing on reverse side. <br /> Signed Tilts:' Date: <br /> FO I"pAEfTMENT USE ONLY t' <br /> Appficati ccOpted by l Date ` '�� L�- Z <br /> _-_ Area <br /> Pit or rout In pection by-�J - Dated Z Final Inspection by <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA-95201 <br /> FEE A UNT DUE AMOUNT REMITTED k, LKRECEIVED BY DATE PERMIT NO. <br /> INFO t p /��7 <br /> + FH 19 2i 1REV.r i rs si t^t J/ v� 1 V ',L/ 1 v -5-7 ��_''/ 7 1 <br /> r FH t�•2E f <br /> f, <br />