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I APPLICATION FOR PERMIT <br /> 4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I 1601 E. HAZHLTON AVE. , PHONE (209)468--3420 <br /> I P O BOX 2009, STOCKTON, CA 95261 <br /> PgMIT -EMIRES 1 YE R FROM DATE ISUED <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the cork 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. <br /> Joh Address O City Get Lot Size/Acreage t2: <br /> Q t <br /> Owner's Name C 4 Address Phone <br /> F <br /> Contractorv,2 Address License No.��_.�Phone- 77 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION. SYSTEM REPAIR 11OTHER ❑ Monitoring Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK 1120 _ SEWER LINES DISPOSAL FLD. PROP. LINE �- r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r/W <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Pr <br /> n Industrial )1 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack n Tracy Type of CasingSpecifications <br /> ` n - - <br /> f`I Public !:1 Qther (l Delta Depth of Grout Seal Type Gra}lo(/v- <br /> e ILS/ <br /> T�� <br /> i I Irrigation 66LO_Approx. Depth l I Eastern Surface Seal Installed by < t n <br /> tj <br /> Repair Work Done U Type of Pump 1 - H•P•3 — State Work Done rl <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> r <br /> Depth .r . Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I -RE PAIRIADDITION I i DESTRUCTION l I (No septic system permitted it public sewer is l <br /> I 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 feet: Water table depot `1 5 <br /> k SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Lina Q <br /> r <br /> LEACHING LINE 0 No. & Length of lines wTotal length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Prdperty Line <br /> F <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 � <br /> 1 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 /> o 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 y' <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." f f <br /> t The applicant must call for all required inspection§. Complete drawing on reverse side. t <br /> Signe X Title: Cr e' .^ Date: C <br /> R DEPARTMENT USE ONLY <br /> AppI on Accepted by <br /> Date 2 ° Area <br /> ! 1 Pit Grou inspection by-(f ISN �''� Date�� �� final Inspection t a Date <br /> Additio Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> i 1.601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 _ <br /> FEf3CK AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY' GATE PERMIT NO. <br /> v INFO <br /> ` Cs7?� / dD 1-7 <br /> w <br /> t + EM 13-24[REV.iisi I <br /> EH 2426 <br /> f <br />