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'1tiJ APPLICATION FOR PERMIT <br /> 1/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 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 Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address N /��Nta City Lot Size/Acreage <br /> Owner's Name .14'4 Address is s 7�JG Phone <br /> Contractor Address Xr_79 License N _Phone �Xa <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.­UNE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SP IONS <br /> M Industrial ❑ Open Bottom ❑ Manteca Dia. �Grout <br /> avation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Specifications <br /> I'I Public I-1 Other Depth ofSeal Typeof Grout <br /> I I Irrigation —.Approx. Dept _ I I Eastern Surface Seal Installed by n <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well�Des truction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> 4 le <br /> TYPE OF 9PTI 'WQRK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTIONMINo septic system permitted if public sewer is C- <br /> available within 200 feet.) <br /> Irmaostion wwsele: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soli to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: -Welf- ^"fou ctati6;' Property Line _400 <br /> LEACHING LINE No. & Length of lines y 7 1 Total length/size Im <br /> r <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth Sizes Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Ltne <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 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 m call for all required insgllllction Complete drawing on reverse si <br /> Signed X Title: -��r�–z- l.�f� Date: <br /> F=Skj%h� <br /> T USE ONLY <br /> Application Accepted by �= Dat ;n-Ci Area <br /> Pit or Grout Inspection by Date Final Inspection bye` 7 '�.� Date 26tl) <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 MOUNT DUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT*NO. <br /> + EH13.21IREV.Iinsi l�.v`-' <br /> EH;42a 0 <br />