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APPLICATION FOR PERMIT <br /> : 1. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL :HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> r P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Se ices. /��.��► <br /> Job Addressd4 ity Lot Size/Acreage /DOA_t <br /> Owner's Name �� Q Address 466191 �(,(1`�1am — Phone ���� i�i <br /> Contract ar S Address <br /> � . l q� Z 7 License too, 9 Z-) f Phone 44 4 S <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION t of Service tfe11 ❑ <br /> PUMP INSTALLATION ">� SYSTEM FIEr+P�fJR ❑ OTHER Ap 171 Monitoring Well <br /> / C7 <br /> DISTANCE TO NEAREST; SEPTIC TANK /SD f� SEWER LINES + � <br /> RISPOSAL FLD. _d�PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _.!W*THER WELL_/40g:2!PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F] Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> W41cmestic/Private L ,ravel Pack Lacy Type of Casing pVG Specifications <br /> I'I Public CI 1 Other F1 Delta Depth of Grout Seal Typ f Gro I. <br /> t I Irrigation Approx. Depth it astern Surf�c Seul Installed by <br /> Repair Work Done �0 Type of Pump H.P. Zy Sta Work Done T <br /> Well Destruction Rr Well Diameter Sealing Material & Depth <br /> Depth Filler Materiel & Depth f (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is �f <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: VK Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r . <br /> Distance to nearest: Well undatio Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED - ­0 Distance to nearest: Well Founcle Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS s L1 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 bb done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County 5 <br /> Home owner or lice agent ignatu►e certifies the following; "I certify that in the,T7erformance of the work fol which this permit is issued, I shall not <br /> employ any pars in such mann as to become subject to an's compensation laws of California." Contractor's hiring of sub-contracting signa <br /> certifies the fo owing: "I certify t a 'n the perform nce of a rk for which th' permit is issued, I shall employ persons subject to workman's comp a- <br /> tion laws of aldomla <br /> The applic nt all squired ' s dr wing o side. <br /> Signe 'X Titl c Date: _16-1 <br /> r <br /> FOR (DEPARTMENT USE ONLY <br /> Application Accepted by Date `� /` Area. 6_1?1b <br /> �velf swat c4r1 tw 6 <br /> Pit or Grout Inspection by Date Final Inspection by ^- fAvs Date _ <br /> Additional Comments.- <br /> Applicant <br /> omments: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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.i i n s) I <br /> EK 14.20 <br />