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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)46$-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PEMIT EXPIRES„J. 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 1$62 an a Rules and Regulations of San <br /> Joaquin County Public Health Services. AIC P; <br /> Job Andress °eu / City�JC 4 Lot Size/Acreage <br /> Owner's Name _ P 7�j�A � Addressrr�j �7//r !`— Phone <br /> Contractor 't N k dress ��J�—CY License No. ?� Phone <br /> TYPE OF WELL/PUMP: NE WELL WELL REPLACEMENT 7 DESTRUCTION Cl Out of Service Well, ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR C OTHER ❑ Monitoring IWell <br /> DISTANCE TO NEAREST: SEPTIC TANK �I SEWER LINES DISPOSAL FLD� PROP. LINE <br /> FOUNDATION G' AGRICULTURE WELL OTHER WELL,.. PITS/SUMPS ,(,Y61 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S <br /> ,I Industrial ❑ Open Bottom © Manteca Dia. of Weil Excavation Dia, of Well Casing <br /> Xbomestic/Private ❑ Gravel Pack (7 Tracy Type of Casing_ 1 Specifications _ <br /> I'1 Public I.] p he E? Delta De th of Grout Seal / <br /> f p TY e of Grout <br /> Irrigation /� pprox. Depth { Itern lace Sedl installed by <br /> Repair Work Done Ll Type of Pump �� g <br /> 3 H. L State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth �e <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTEON E I (No septic system permitted if public sewer is \ <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial — Other c� <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mf J <br /> g Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE L� No. & Length of lines Total length/size ` <br /> FILTER SED 1-1 Distance to nearest: Well _ Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS (-I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that tate 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 to is issued, I shall em <br /> tion laws of Califo Ia.- p Y persons subject to workman's compensa <br /> The applicarustn all r quired ' f Complete drawing on revers side. <br /> .. <br /> Signed ?( Title: � � Date: <br /> ,Ut OA PARTiMENT USE ONL <br /> Application Accepted by 1 b Dat® �a l c( - Area <br /> Pit or Grout Inspection by 'Date tri- � <br /> Final Inspection by Dat jo <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joar,uin 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 REMITTEDCK <br /> 'S INFO ASH pECEfVED !3Y DATE PERMIT NO. <br /> + EH 13-24 iREV,i i n 5z _7/� 9 <br /> EH;4.26 G V �CJ�-� C" ��, F-i,�f (G 7t;' � <br />