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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION OLt L-0-�- 0 F <br /> 1601 p•O BOX 2009 <br /> AVE. , PHONE <br /> V01-3420 <br /> v <br /> PERMIT EXPIRES 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. <br /> Job AddressIZO_4LZ�� City Lot Size/Acreage f e <br /> i <br /> Owner's Namedress Phone <br /> Contractor ess License NO Phon , <br /> TYPE OF WEL /PUMP: NEW WELL O WELL REPLACEME T ❑ DESTRUCTION 0 Out of Service Well <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well C� <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 /> n Industrial 0 Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> 1'I Public 11 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction D Well Diameter Sealing Material & Depth <br /> Depth Fille'r-�erial I epth ill <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION? , DESTRUCTION I I INo septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other \ <br /> Number of living units: Number of bedrooms 1 Y <br /> 'Character of soil to a depth of 3 feet- <br /> 9 <br /> eet: Water table depth <br /> SEPTIC TANK 0 Type/Mfga'pacity7 �-- No. Compartments <br /> PKG. TREATMENT OLT.1=1-----__ Method of Dispggal <br /> L/ <br /> Distance to nearest: Well 10 D Foundation/ .— Property Line,F ! <br /> LEACHING LINE Cl No. & Length of lines Total length/size r^j <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line V <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Irl 0 Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I 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 /> 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 tnust call for all q}ired insPecti S. mplete drawing on reverse side. <br /> Signed X Title: , �'� Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 2 <br /> it or Grout Inspection bye Date 4 _1?1/ Final Inspection Date <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 REMITTED CK RECEIVED BY DATE PERMIT'N0. <br /> INFO i �CASH <br /> . EH 13-24 IREV.i i x s t �i �`� l�V` •� IR, <br /> EH 14.26 ll <br />