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APPLICATION. FOR PERMIT <br /> 'ZI�a <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46873420 <br /> P,O BOX 2009, STOCKTON, CA 95201. <br /> MMIT EXPIRES-1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> ti <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. <br /> Job Address 1 S �� I� City c Lot Size/Acreage <br /> Owner's Name4dC -y Address/G f f Phon'? r �0 + <br /> i <br /> Conlraclor a Address T(� License No, 7 Phone <br /> TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [% Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing ' Specifications <br /> I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> ! I Irrigation —Approx. Dept 1 1 Eastern Su ace Seal Installed by ! _ <br /> Repair Work Done a Type of Pump ' H.P. __ _Lf� _ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth ttqJN <br /> Depth Filler Material & Depth I <br /> 3 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITIO_N 11 DESTRUCTION I I lNo septic system permitted if public sewer is <br /> available within 200 feet,I <br /> Instalfation will-serve:—Reslderice"^'G6mmercial_`- Other <br /> Number of living units: Number of bedrooms <br /> .Character of soil to a depth of 3 feet: Water table depth t. <br /> YSEPTtC TANK ❑ Type/Mfg CapacityNo. Compartments�r �• <br /> PKG. TREATMENT-PLT.`❑ '; llrm.thod of�Disposal � <br /> 70istance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING•LINE ,! I4 L1 NO,.& Length of lines Total length size <br /> FILTER BED C1 q sten o nearest Well Foundation Property Line J <br /> SEEPAGE PITS 11 Depth. Size _ 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 will be done in accordance with Sart-Joaquin county ordinances, state laws, ander- <br /> rules and regulations of-ihe San Joaquin County 4� <br /> Home owner or licensed agent's signature.ieriifiss the following: "I certify that in the Wormance of the work for <br /> which thisP ermit is issued, l shall not ' <br /> employ any person in such manner as to bec6die subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 /> The applicant ust call for all required inspegtions. Complete drawing on reverse side. <br /> Signed _. . "� 'C'` itle.:..-- _ � '..'*`---^'Data:"? <br /> FOR DEPARTMENT USE ONLY ; <br /> s <br /> Application Accepted by Date I � Area <br /> Pit or Grout Inspection by Date Final Inspection by-4 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public,Health <br /> Services, Znvironmental,Health Permit/Services <br /> 1601 E. Hazelton Ave., P,:O_Box 2009, Stockton, CA 95201 <br /> FEE CK 9 <br /> NFO <br /> IAMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT'NO. <br /> EH 3-24 i `f <br /> « EH 34.�p IREV.t i n sl 7 00 �� �] r�`-� <br />' ,— Cl V <br />