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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, 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 in coag111ance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> f -� /. City ki'-�+ Lot Size/Acreage <br /> Job Address -��"� �`� <br /> Owner's Name Bel, Address Phone <br /> Contractor <br /> 1/1 /I,,l Address 'l A' License No.15Z17, 'y Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well D <br /> PUMP INSTALLATION O SYSTEM REPAIR OTHER O 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 /> L3 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications \ , <br /> Il Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth 1 I Eastern Surface Seal Installed by ( p <br /> Repair Work Done U Type of Pump 5" f H1'" H.P. State Work Done <br /> Well Destruction O Web Diameter Sealing Material • Depth v <br /> Depth Filler Material i Depth (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I 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 of bedrooms <br /> Character of sob to a depth of 3 feet: We th v, <br /> SEPTIC TANK. D Type/Mfg Capacity- <br /> PKG. <br /> apacity PKG. TREATMENT PLT.D Ma" <br /> Distance to nearest: Well Foundation Propertl 4 <br /> 73 <br /> LEACHING LINE 0 No. b Length of lines Total Ion <br /> Pyhlslz 7Z <br /> FILTER BED ❑ Distance to nearest. Well Foundation <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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 unify 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 mus for all required inspect{ ns. <br /> Signed Complete drawing on reverse side. <br /> b.., Title: /?'L;1A4ej1.- Date: fix z <br /> OR EPA <br /> RTMENT USE ONLY <br /> Application Accepted by Date Area , <br /> Pit or Grout Inspection by Date Final Inspection by Oats <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> IV <br /> FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT'N0. <br /> INFO <br /> . EM 13-24 IaEV.1 bl 17 /� � <br /> EM 142/ v <br />