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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISum <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 Address __X 12 /� �lyQ/�//L ,' / C <br /> / City SX< Lot Size/Acreage <br /> Owner's Name f�V 1 1 �rnG.• <br /> Address Phone3 2"7 <br /> Contractor � Address /�y 1,jax l?,OF- 73�" y-- <br /> z� <br /> TYPE OF WELL/PUMP: License No ) Phone <br /> NEW WELLi WELL REPLACEMENT _ DESTRUCTION O Out of Service Well ❑ <br /> PUMP INSTALLATION JSC SYSTEM REPAIR ❑ OTHER O Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESC7 <br /> 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 O Open Bottom ❑ Manteca Dia. of Well Excavation <br /> LDomestic/Private .ryGravel PackDia. of Well Casin b <br /> /� ❑ Tracy Type of Casing109P.11-c- X <br /> I') Public El Other n Delta Specifications <br /> C-> Depth of Grout Seal /� Type of Grouts.'Gll ,tW I <br /> I I Irrigation LS —,Approx. Depth I I EasternDC7 <br /> Repair Work Done U T �� Surface Seal Installed by_ �' � <br /> Re <br /> p Type of Pump �______ H.P. — 1 <br /> Well Destruction O Well Diameter Sealing Material & Depth State Work Done <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is <br /> Installation will serve: Residence CommercialOther available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK O Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity______,_, No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation_ Property Line <br /> LEACHING LINE C1 No. & Length of lines 1 <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth <br /> SUMPS Size Number <br /> LI Distance to nearest: Well Foundation <br /> DISPOSAL PONDS U — Property Line <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 /> 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 certifythat in the performance of the work for which this permit is issued, I shall employ <br /> tion laws of California." <br /> P V Persons subject to workman's compensa- <br /> tion <br /> applicant must 11 f all required inspections. Complete drawing on reverse side. <br /> Signed X ,.` <br /> ` Title: (Cq_4_n -. q <br /> Date: s <br /> FM DEPARTMENT USE ONLY <br /> Application Accepted by / ��9 1 ( 1 <br /> — ` <br /> Pit or Grout Inspection by Date Area <br /> Date Final Inspection by 7I/�4- <br /> I /�. <br /> Additional Comments: Date <br /> A <br /> Applicant - Return all copies to: San Joaquin Cour <br /> q y 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 <br /> INFO CASH RECEIVED BY DATE 0 <br /> PERMIT'NO. <br />' EH t�.-24(REV.i i x sl O� (� <br />