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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 111 1601 E. HAZELTON AVE. , PRONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EgP RES 1 YEAR FROM DAIR 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> 1 /Job Address e City Lot Size/Acreage <br /> /D 99 I f- <br /> Owner's Name ^` Address Phonu <br /> C4 _ ` f� Phone <br /> Contractor.._ �— Address License Nv.R � `��J <br /> TYP --OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL t PROBLEM ARE NSTRUCTION SPECIFICATIONS ia Off <br /> f p _ <br /> C]] Industrial D Open Bottom D Manteca Dia. of cavation Dia. of�Well Casing �V <br /> M Domestic/Private 0 Gravel Pack D Tracy Type of Casing Specifications <br /> i'l Public I-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrioation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter ' sealing Material 8 Depth t <br /> Depth )Filler Material S Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADOtTION I i DESTRUCTION iNo septic system permitted if public sewer is <br /> ava+lable within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: Water table depth n, <br /> SEPTIC TANK. ❑ Type/Mfg .Capacity No. Compartments 1 <br /> PKG. TREATMENT PLT-❑ Method of Disposal <br /> .�•-^ "'"'-Distance to nearest: Well Foundation Property Line <br /> I LEACHING LINE ❑ No. B Length of lines { '- / Total length/size <br /> FILTER BED O\Distance to nearest: Well Foundation �-� Property Line <br /> SEEPAGE PITS �'I ) Depth Size _ Number <br /> SUMPS C3 Distance to nearest: Well 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 /> t rules and regulations of the San Joaquin County f <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 became subject to workman's compensation laws of California."Contractor's hiringror 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 subie'ct to workman's compensa- <br /> tion laws of California." s y �I <br /> The applicant ust call for all requ'r0 inspe. ions. Complete-drawing on re rse,side. f <br /> XSignedyTitie <br /> fR DEPARTMENT USE ONLY <br /> yApplication Accepted by L Date Area ` <br /> G /z <br /> Pit or Grout Inspection by Date Final Inspection by Date b <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> y Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUI: AMOUNT REMITTED CK <br /> 9 RECEIVED BY DATE PERMIT NO, <br /> INF <br /> + EH 13.24IREY.1185) � p � a/ L 70 <br /> �U- f <br /> EN 7428 t•��+ <br /> F <br />