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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> VIROHEALTH DIVISION R%r% <br /> 1601 E.�HAZELTONNTAL AVE. , PHONE (209)468--342 ` INAf, FD <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> -PEMT_ EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete is 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 Address r ti 0</ City -.II70z/e� Lot Size/Acreage �QIJ <br /> Owner's Name Address Phone <br /> Contractorv Address L.C/r ` License No" 7 Z Phone 3 <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> fl Industrial 0 Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private D Gravel Pack Ll Tracy Type of Casing Specifications <br /> 1'1 Public 1-1 Other rl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ,_,_..Approx. Depth I 1 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 1 REPAIR/ADDITION IGF- DESTRUCTION l 1 iNo septic; system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence Commercial— Other , .� <br /> Number of living units: Number 9f bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth O i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines �� ��, ,:, Total length/size V <br /> FILTER BED 0 Distance to nearest: Well 3 Foundation /D f Property Line 1CI7a ' <br /> SEEPAGE PITS I'r Depth _ Size 3 r` _ Number <br /> SUMPS Ll Distance to nearest: Well 00 1 Foundation /d' Property Line r `y <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 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 taws 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 California." <br /> The applicant must call for all re vire inspections. Complete drawing on reverse side. <br /> X <br /> Signed ©fill I4�C� <br /> 9 *. ,.,., Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Area <br /> f or Grout inspection by Date� ��6 <br /> Final Inspection by 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 <br /> INFO AMOOUNfT DUE AMOUNT REMITTED ASH RECEIVED BY `DATE q PERMIVNO. <br /> . EH 13-24'14-204.4� 1REV.riHSl V ' � �✓ • � r f <br /> EH 2e ""T �J <br />