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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ^ ENVIRONMENTAL HEALTH DIVISION <br /> v\ v. 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> V\ P O BOX 2009, STOCKTON, CA 95201 <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 OgAinancgyNo. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Publi Health ervicea <br /> Job Address itY <br /> r/•�j�r?y( ' Lot Size/Acreage < <br /> � �� <br /> Owner's Name `t�/YL�� Address ZV /r' ' /"�'-as a`�v' /yC Phone <br /> Contr for 7-9' XP� 6 �J <br /> Address [ � �/7�( � License No. L&7 Phone <br /> TYPE`OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST, TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATI AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROB A CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial O Open Bottom O Manteca Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack O Tracy Type of Casi Specifications <br /> Il Public 1.1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation w ve: 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines otal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation rtyLins <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 s, 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: "1 certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- <br /> tion laws of lifornia." <br /> The appli t II f uir pections. mplete drawing on ver side. / !k <br /> Signed Title: ��� Date: 7/7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted bDate Area Z ( � <br /> Pit or Grout Inspection by Date Final Inspection by-2) Q,, Date C) <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 <br /> ��DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N�O. <br /> a EM 13-2�(REV.t/M 5! �•U O 17 �ct <br /> EN 11.20 <br />