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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 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 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public <br /> Health Services. D / ,, ,, <br /> Job Address `s v,/ ' ` City - Lot Size/Acreage <br /> Owner's Name ��!SLG Address �/ � � y r7Phone �1 C <br /> /'�G7ff �j E `�i2 License No. �/ Phone�7 '2// <br /> Contractor Address <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION O SYSTEM REPAl� OTHER O <br /> Monitoring Well <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 /> O Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br /> FI Domestic/Private O Gravel Pack O Tracy Type of Casing_ Specifications <br /> I'I Public El Other n Delta Depth of Grout Seal Type of Grout <br /> gation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repan Work Done U Type of Pump <br /> H.P. d State Work Done e go6&l� <br /> Sealing Material & Depth 7 i� <br /> X-_Zz& <br /> Well Destruction O Well Diameter C2� 5 ro <br /> Filler Material & Depth T� �� 11014aAg�lZ- <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is e <br /> available within 200 feet.) C'ffA4,te6i� <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms _sell <br /> of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT, O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: Well Foundation Property Line <br /> r� <br /> _ \ <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <br /> 1 hereby certify that 1 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, 1 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 laFg <br /> ifor a." <br /> The au a I requ' ins cti_ Complete drawing on reverse s� �- A91SigneTitle: ���1/z.4C/�°� Date: ` <br /> OR DEPARTMENT USE ONLY I <br /> Application Accepted by -� — Date _ Area <br /> Pit or Grout Inspection by Date Final Inspection <br /> Additional Comments: 1 <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 AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'N0. <br /> INFO CASH I <br /> -7-17-2 <br /> ]`1 q <br /> EH 1;A-MEV.!iMS� ,OO .0'0 Z�L '7� • ,2 f -tf <br /> If <br /> EH 14.26 1 <br />