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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 BOX 2009, STOCKTON, CA 95201 <br /> REMIT EXPIRES 1 YEAR FROM DATE ED <br /> (Complete in Triplicate) 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 theRules and <br /> �Regulations <br /> of San <br /> Joaquin County Publi Health Services. /✓ 0 Z <br /> -7 Q�p7 Jt�. D Z1/✓C <br /> 4--1 ' �D City I-IN0 4 Lot Size/Acreage <br /> Job Address Cs TN i D C r_.� <br /> Phone <br /> Owner's Name - ('r)fLT�� S / _ Address � �1 <br /> Contractor N�� <br /> Address M-JT_ License No.50 rt 3 Phone <br /> NtLq2L TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> SYSTEM REPAIR OTHER C3Monitoring Well <br /> PUMP INSTALLATION ❑ a� <br /> ° DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> - <br /> FOUNDATION AGRICUtf-URE-W£RL� -- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Open Bottom ❑ Manteca V Dia. of Well Excavation Dia. of Well Casing <br /> Industrial } <br /> _ Type of Casing- Specifications <br /> EI 1 RomesGclPrivate ❑ Gravel Pack L7 Tracy Yp 9 Type of Grout \ i <br /> I'l Public El Other n Delta y Depth of Grout Seal �l <br /> �lrrigatiort Approx. Depth l I Eastern �, Surface Seal installed by <br /> I <br /> Type i t� C H.P., 240 State Mork Done <br /> Repair Work Done <br /> p X Te of Pump ---.Sealing 1materiel&_Depth,_ <br /> Well Destruction ❑ Well Diameter T Biller Material Depth &V` <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/AODITION I I DESTRUCTION I 1 {No septic system permitted if public sewer is j I <br /> available within 200 feet.) 1� <br /> I <br /> Installation will serve: Residence_ Commercial <br /> Number of living units:. Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Type/Mfg —r! Capacity No. Compartments <br /> SEPTIC TANK ❑ C <br /> PKG. TREATMENT PLT. ❑ � j Method of Disposal <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 � Property�Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI 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 San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County e <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, l shall not <br /> +' employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub Contracting signature <br /> 1 certifies the fallowing: "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 m9acall for all equire ins ns. plate drawing 9w7ever sid0. <br /> Signed X <br /> Title: Date: - <br /> DEPARTf9AEN7 USE ONLY ^� <br /> Application Accepted by Date , - Area <br /> Pit or Grout Inspection by Date Final Inspection by��yl— Date / <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> i Services; Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 LIS <br /> RE <br /> AMOVNT DUE AMOUNT REMITTED ASH RECEIVED 8Y DATE PERMiT'NO. <br /> EH13.24(REV.sinss11 -� <br /> mEH 9{26 - <br />