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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 ''W 3 <br /> -EXPIRES 1 YEAR7FR M DATE ED <br /> (Complete- in Triplicate) _fin C3�3 C --CZ <br /> Application is hereby made to San Joaquin County forermit 4 <br /> application is made in compliance with San Joaquin county ordinancenNo. 549Bandstruct Q18628talland tleo Rules and,the workein Regulationsdof Sans <br /> Joaquin County Public Health Services. <br /> CA 5?` 0 t D P,1J I-� ITZ Q - <br /> Job Address �NU2 a 0 �j��Vt� <br /> City <br /> 1 f �'V Lot Size/Acreage f <br /> Owner's Name L- t A ~W� �C <br /> �N& Address ).'�X�!L� ������q.S?�� Phone S <br /> f J 7—... <br /> Contractor2 d Address (> f r f <br /> License No.� � .� Phone <br /> TYPE OF WELL/PUMP: / NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well 0 <br /> PUMP.INSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES DISPOSAL FLD. PROP. LINE fa t <br /> FOUNDATION, f AGRICULTURE WELL OTHER-WELL PITS/SU4seweris <br /> INTENDED USE TYPE OF WELL /PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E Industrial ❑ Open Bottom :` ❑ Manteca Dia. of Well Excavation Y Dia. of Well <br /> Cl Domestic/Private ❑ Gravel Pack/ ❑ Tracy Type of Casing Specification <br /> I'I Public 0 Other n Delta Depth of Grout Seal Type of GroIrrigation /Approxi Depth-•---I--I-Edswrri �"�-TSGrface-Seal-tnstalled bq--Repair Work Done ❑ Type of Pump c( W.P. _Z2) State Work DoneWell Destruction ❑.11!. WeN Diameter Sealing-Material`&.D th Depth Filler Material & Depth �,A)[� —, ,_TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted 4 <br /> ` available within 200 feet.) a <br /> Installation will I serve: -Residence_ Commercial_ Other I <br /> Number of living units: Number of bedrooms , • I ' <br /> Character•of sail to a depth of 3k feet: '- -' t Water table depth ;I <br /> SEPTIC TANK. p Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal Y <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation '2' Property.Line <br /> SEEPAGE-PITS---•--1-1—Depth--—�.._ -Size Number---- <br /> SUMPS LI Distance to nearest: Well Foundation Property Line F <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin cou y 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 /> tion laws of California." <br /> The applican call for all required�ctions Complete drawing o ver r side. it <br /> Signed c�7 Title: �� fcj 0,0 <br /> Date: <br /> ARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection byc_ <br /> Date:r1. <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 95241 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br />. EH A3n <br /> )REV,rise <br /> EH 26 <br />