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APPLICATION FOR PERMIT <br /> w <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> P%RMIT_EXPIRES 1 YEAR FROM DAZE ISSUED <br /> or=s S T (Complete In Triplicate) 2ZZ - .350- 5u <br /> i,. <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. 771','4-C-T__ <br /> ��r— ,fir q <br /> Job Address 7_ RNXU IZs x,23 7`? AA T r <br /> City at Size/Acreage LJ <br /> Owner's Name _ y/ �/ �V !l! _ &:)C .2(1,3 Phone V 7 <br /> Contractor U/P 14 ��A4adrf �'dLicense No. O .Ph e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DES UCTIONOut o Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ onitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL P LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> FI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private LII Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public !-1 Other 1 n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work pone ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material b Depth ' <br /> 1 <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTM5@9EDo septic system permitted if public sewer is (�1 <br /> ailable within 200 feet.) l� <br /> installation will serve: Residence Commercial - Other <br /> Number of living units: Number of bedrooms N <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, Gl Method of Disposal <br /> to <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest. Well Foundation Property Line , <br /> SEEPAGE PITS 11 Depth I Size Number <br /> SUMPS LI Distance to nearest: Well Foundation- Property Line <br /> DISPOSAL PONDS ❑ I ) <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 laws, ani _ <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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub contracting sigall no <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 compensate <br /> tion laws of California." . r ub . <br /> The appiican r all requir spections. Complete drawing on reverse side, <br /> Signed X TitlA <br /> Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by � Date 3 res <br /> Pit or Grout Inspection by Date Final Inspection by DateJ�� 6 <br /> Additional Comments: ✓ .� cCr �/ �n/l <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE <br /> CASHPERMIT'No. � <br /> INFO /�} <br /> * EN i�26 [Y �V `r O � <br /> CH 13-24(REV. J 3( �� <br /> lid <br />