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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 O BOX 2009, STOCKTON, CA 95201- <br /> PEWIT <br /> 5201PERMIT EXPIRES 1 YEAR-FROM DATE_ ISSUTD- <br /> (Complete in Triplicate) . ��, . . <br /> .,. <br /> Application is hereby made to Ban Joaquin County for a permit to construct and/or-install thework'-tierein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and•-the,'Rules and RegulationB-Of San <br /> Joaquin County Pu)�]lic Health Services. <br /> Job Address J � + City `at Size/Acreage <br /> Owner's Name Address Y,_ Phone <br /> r Contractor dress License No. -& 4 PhorW�g��� <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT C1 DESTRUCTION ❑ Out Of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD." PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS f <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack 11 Tracy Type of~Casing Specifications t L} <br /> A, . v <br /> I') Public CI Other 171 Delta Depth of Grout Seal Type of Grout [" <br /> I I Irrigation' 'Approx. Depth l I Eastern Surface Seal Installed by O <br /> Repair Work Done 0 Type of Pump t H.P. State Work Done _ <br /> Well Destruction O Well Diameter . Sealing Material & Depth ' <br /> 47- <br /> Depth Filler Material &.Depth ' ' I <br /> TYPE OF SEPTIC WORK: , NEW INSTALLATION l I REPAIR/ADDITIO " 'DESTRUCTION I i (No septic system permitted if public sewer is Zff y available within 200 feet.) <br /> Installation will serve: Residence Commercial, Other - 1 <br /> Number of living units: Number of bedrooms <br /> Character of soil lo-is depth of 3 feet: _ Water table depth <br /> SEPTIC TANK , ❑ Type/Mfg Capacity No. <br /> Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> } Distance to nearest: Welt Foundation' b Property Line <br /> LEACHING LINE C1 No. & Length of lines Tot I length/size <br /> FILTER BED C] Distance to nearest: Well r Foundation .Property Line I <br /> 1 <br /> SEEPp-GE PITS 11 Depth Size ' t- Number ` <br /> 1-7 <br /> SUMPS CI Distance to nearest: Well ajf 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 t <br /> Home owner or licensed agent's signature certifies the following: "l certify that in the performance of the work for which this permit is issued,rl 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 fallowing: "I certify that in the performance of the work for which this permit is issued, i shall employ persons subject'to workman's compenss <br /> tion laws of Cali rr' <br /> The applicant must call r all a ired ins c ' s. Complete drawing on reverse side. <br /> Signed)X Title: K Date: <br /> FOR DEPARTMENT USE ONLY r� / <br /> .Application Accepted by Area <br /> Ir0Grout Inspection by ` �� Final Inspection by L:4 rt�/U�/ Date r 91, <br /> t <br /> Additional Comments: <br /> Applicant _ Return all copies to: San Joaquin County Public Health k <br /> Servicea, Environmental Realth"Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE \C�7 <br /> INFO AMOUNT DUE OUNT REMITTED 42 CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 14.2e I REI/.r i N 51 <br />