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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 BOR 2009, STOCKTON, CA 95201 <br /> PENIT MIRES 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and-the Rules and Regulations of San- <br /> Joaquin County Public /"�Health Services. o/ <br /> `� L <br /> Job Address ic5-1 E. &nn i LE .2 o City ` � Lot Size/Acreage <br /> f <br /> Owner's Name �IA&law _M�� [�fA.s'�z"Address A Phone !J <br /> I <br /> Contractor AddressAJ License No.&SV ��Phone r! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0. DESTRUCTION O Out of Service Well 0 <br /> PUMP INSTALLATION SYSTEM REPAIR ❑' OTHER 0 Monitoring Well L <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL : PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation y Dia. of Well Casing <br /> � r <br /> Domestic/Private 0 Gravel Pack Ll Tracy Type of Casing Specifications <br /> I'I Public 1-1 Other 171 Delta Depth of Grout Seal Type of Grout <br /> + I I Ifrigalion —Approx. Depth I ) Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump - �5 CI$6— H.P. 9 beP State Work Done 0 <br /> r a`! <br /> Well Destruction O Well Diameter c Sealing Material & Depth I I <br /> Depth Filler Material & Depth T Iti_.! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I i DESTRUCTION I i INo septic system permitted if public sewer is ` <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 Water table depth <br /> SEPTIC TANK. 1 0 Type/Mfg,'' Capacity _ No. Compartments <br /> PKG,`TREATMENT PLT. ❑ Method of Disposal , <br /> Distance to nearest: Well Foundation Property Line t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line V <br /> F <br /> SEEPAGE PITS 1 ) Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 ^►1` �j <br /> I hereby cenify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and t <br /> rules and regulations of the San Joaquin County <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 become subject to workman'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 f at{for all required iMections. Complete drawing on r ree sr <br /> Signed X Title: _ � Date <br /> �� : <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date r <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by r, Date�� Er <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 O Box 2009, Stockton, CA 95201 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMIT-TEDI <br /> ASH %C E//VVED BY DATE PERMITN0. <br /> . E 13.2 IREV.sinslPiz . <br /> EHM'r{-26 <br />