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„APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 160 . E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM-DATE IggUED <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 Ordi nce No. 549 and 1862 and the Rules and Regulations of Sa // <br /> Joaquin County Public Health Services. I� y� d )� <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address471- 4�ryl��> JJ�� Phone <br /> L f � 5 <br /> Contractorffam `5 Address _fR1P� ��li�- fib License No.14��Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 7 <br /> ,�--DESTRUCTION71E&Tt of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ln Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �1 <br /> Ea Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'l Public i t-1 Other F1 Delta Depth of Grout Seal Type of Grout G <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump tIH.P. State Work Dona 6 <br /> Wel! Desiructiory5 ❑ Well Diameter 6�^ IOlSealing Material A Depth <br /> Depth — Filler Material & Depth h <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet,) { <br /> Installation will serve: Residence— Commercial— Other M <br /> t <br /> Number of living units: Number of bedrooms j <br /> �. Character of soil to a depth of 3 feet: Water table depth >• <br /> SEPTIC TANK ❑ Type/Mfg Capacity— No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal T <br /> r w Distance to nearest: Well Foundation Property Line j <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED l 1) Distance to-nearest: Well r Foundation Property Line <br /> 4.to <br /> SEEPAGE PITS 11 Depth ' ti Size S Number <br /> e_ j <br /> Y <br /> SUMPS LI Distancto nearest: Weil Foundation property Line <br /> DISPOSAL-PONDS ❑ ' <br /> I hereby certify that I have preparaci 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 <br /> Home owner or licensed agent's signature certifies the following; "I certify that in the performance of the work_for which_this_parmit.is issued, I shall not <br /> employ-any-person-in such-manner-as-to-become subject to workmsn's compensation laws o}CaGfomia.” Contractor's hiring or sub-contracting signature t <br /> certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shalt employ persons subject to wor an's compensa- <br /> tion laws of Californi�t ­ <br /> "' <br /> The applicr quire omplete drawing on reverse side <br /> Signed ills:. - Date:. <br /> DEPARTMENT USE ONLY �- <br /> Application Accepted by { � r ;t d 'D <br /> Date i� Area - <br /> Pit or Grout inspection by Date 4; Final Inspection by Date V <br /> y <br /> Additional Comments: ' <br /> Applicant - Return all/copies to: .San Joaquin County Public Health <br /> J Services, Environmental Realth Permit/Services <br /> f 1601 E. Hazelton Ave., P O.Box 2009, Stockton, CA 95201 <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED y CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 1REV. i K SI �j� 7. , <br />