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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION y <br /> 1601 E. HAZE'LTON AVE. , PHONE (209)468-3420 R <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 _YEAR FROM DATE 15SUED <br /> (Complete in Triplicate) <br /> Application is hereby tnade.to San Joaquin County for a permit to construct and/or install the work herein described. This F <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 /> Job Address <br /> Z/0 / City C V Lot Size/Acreage �l <br /> i <br /> Owner's Name G-" Address Address Phone <br /> i vGGG _ Address �i8 Phone +r <br /> Contractor . _ .LS !S!rr /Y`P/N '_License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION'17-- SYSTEM REPAIR ❑ 'OTHER'❑ ^ .14onitoring-Well-.[]_ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> .- ... <br /> ——FOUNDATION- AGRICULTURE WELL ___ - ,OTHER.WELL, ;PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> n industrial D Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack 0 E Tracy Type of Casing Specifications <br /> I') Public - - 1-1 Other -..f 1,Delta Depth of Grout Seal' Type of'Grout=e <br /> I I Irrigation _. _Approx, Depth Cl Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump H.A. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> 't <br /> 'Fi11er.Material`&-'epth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is \ <br /> I available within 200 feet.) <br /> Installation will serve. Residence_Lf' Commercial_ Other— I <br /> ft M <br /> Number of living units: 4— Number of bedrooms <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK. El Type/Mfg -21 Capacitvz&/_i�hP No. Compartments ; <br /> i <br /> PKG. TREATMENT PLT..❑ Method of Disposal I <br /> Distance to nearest: Well Foundation Property.Line U F <br /> LEACHING LINE 0 No. & Length of lines ` "/yam!_ Total length/size t <br /> FILTER BED ❑ Distance to nearest: Well Foundation F'7_ Property Line Z0 <br /> Y <br /> SEEPAGE PITS 11 Depth Size Number l <br /> SUMPS L) Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the worst for which this permit is issued, I 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 /> certifies the following: "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 must call for all required insPections. Complete driwing-on reverse side. �} <br /> I, <br /> Signed X Title: ��-�+�.Q Date: <br /> F <br /> 'FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 6 Area <br /> Pit or Grout Inspection by Date Final Inspection by eA _els o <br /> Additional Comments: <br /> 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 AMOUNT DUE AMOUNT REMITTEDCK RECEIVED By DATE <br /> /CASHPERMIT'N0. <br /> INFO <br /> EH 13.24 IREV.1/”51IP- b <br /> EH 14.26 1.0 <br />