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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �4_9(� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Completer 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. + I <br /> Job Address / C! k/cT- l <br /> �J"- ,e Cite t. _ Lot Size/Acreage <br /> Owner's Name Address Ll '�U0 <br /> Contractor P ✓ Address,(( �� R License Nor b-13 73 PhoneT ^9� <br /> TYPE OF WELL/PUMP: NEW WELL, ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 11 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial { ❑ Open. Bottom ❑;Manteca i Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private—--D-Gravel Oack— -•--C7-Tracy . j -TypeAf-Casing Specifications <br /> I'l Public i 1-1 Other f-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irritlation _..Approx. DepAb I I Eastern � Surface Seal Installed by r <br /> Repair Work Done: Le Type of Pump �4'V6'"-t H.P; State Work bone L <br /> Well Destruction ❑ Well Diameter Sealing Materiel & Depth <br /> r <br /> _ l Depth Filler Material & Depth () <br /> TYP-EsOF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION t I (No septic system permitted it public sewer is <br /> I i available-within'200 feet) {� <br /> Installation will sirve: Residence Commercial— Ot'Eher y <br /> Number of livinglunits: Number of bedrooms 1i <br /> Character of soil Ito a depth of 3 feet: l Water table depth f <br /> SEPTIC TANK ❑ Type/Nlfg __—_ Capacity'f v No. CompartmentsPKG, TREATMENT P_LT. L _' <br /> Method of Di <br /> r rr —Y—°• _ �._-- ".'i. 4 - w� _ �.+ sposal Q <br /> E Distance to neatest: Well i Foundation Property Line <br /> LEACHING UNE i D No. & Length of lines Total length/sire <br /> FILTER BED i ❑ Distance to nearest: Well Foundation ',Property Line <br /> SEEPAGE PITS 1 ) Depth Sire' -_I I Number <br /> SUMPS F LI Distance to nearest: Well t- Foundation Property Line <br /> DISPOSAL PONDS ❑ } <br /> 1 hereby certify that I'have prepared this application and that thelY4ork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County c <br /> Home owner or licensed agent's signature certifies the following:1"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 workrtr'an's compensation laws of California." Contractor's hiring or subcontracting 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 Callforkla." <br /> Thea licant ust'call for all r uired ins <br /> pp pections. Complete drawingil; on reverse side. <br /> l <br /> Signed X _..i U".�'�u T Title .__�" �Yi/ _._..._ Date: Com - <br /> FOR DEP TfuIENT USE ONLY <br /> Application Accepted by Date__ _ " / Area <br /> Q r <br /> Pit or Grout Inspection byDate Final Inspection b � Data <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 INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE ' PERMIT N0. <br /> EM t4 <br /> + EH t3.24(REV.1/RSI2e 3 <br />