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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)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEARFROM DATE ISSUED <br /> (Complete in Triplicate) <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 __._ � } _ _ l - lti'i�l� City iA deh Lot Size/Acreage �_ <br /> Owner's Name + - - �_��h_ __ _ 4ddress., F'-�0.` �dW��% Phone �� <br /> Contractor }~ Address (001V q-ax=aVLicense No. 3�Phone-722- <br /> �6� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR C7 THER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK 5 SEWER LINES r DISPOSAL FLD.ac 0 f PROP. LINEg <br /> 1g FOUNDATION AGRICULTURE WELL OTHER WELL Sop PITS/SUMPS + <br /> F ' <br /> INTENDED USE TYPE OF WELL _PROBLEM AREA CONSTRUCTION SPEOFICATIONS 1/ <br /> n Industrial _.. Open Bottom ­ Q Manteca Dia. of Well Excavation - Dia. of Well Casing <br /> Domestic/.P.rivate; ,0,Gravel.P.ack 0 Tracy Type of Casing ��� Specifications <br /> - <br /> ['I Public E Other p F1 Delta Depth of Grout Seal 00 Type of Grout <br /> I I Irrigation .Approx. Depth I I Eastern Surface Sedl Installed by f <br /> Repair Work Done 0 Type of Pump H.P. -State Work Done <br /> Well'.Destruction O Well Diame. Sealing Materia Depth k + t <br /> Depth Filler Mate 1 & Depth � j <br /> �,TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAfR/ADDITION--1-4—DESTRUCTION I I INo septic system permitted if public sewer is <br /> Vii' ± available within 200 feet.) <br /> Installation will serve: Residence Commercial_`'-_Other <br /> -4.. of living units: Number of bedrooms O <br /> Character of sall to a depth of 3 feet: ""- - - Water table depth r <br /> SEPTIC TANK ❑ Type/Mfg —r achy No. Compartments <br /> ..--7PK6: TREATMENT PET. ❑ Method of Disposal <br /> Distance"to nearest: Well " Foundation " Property line ' <br /> f <br /> "Alt <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED [7 Distance to nearest: Well e � „Found Property Line# <br /> 3 F ` ! <br /> SEEPAGE PITS I I Depth Size ; Number f <br /> SUMPS LI Distance to nearest: We ��.° Foundation-' Property Line <br /> DISPOSAL PONDS ❑ 1 <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, 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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> s' <br /> The applicant m all for all re fired i lana. Complete drawing on reverse side. /f i <br /> Signed Title: Date: <br /> OR DEPA'RTMEN7t,\USE'ONLYMi p. <br /> 1 <br /> Application Accepted hyo-x Area r <br /> Pit or Grout Inspection by� Date, , YFinel Inapectio by Data (1 A <br /> Additional Comments: <br /> r <br /> Applicapt - 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 K <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEFVED BY DATE PERMIT NO. <br /> 4 <br /> : EH 13-24 tREv.1,n 51 <br /> EH 14-26 s <br /> 8 <br />