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APPLICATION FOR PERMIT <br /> �1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 0^T 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 (Va G/ CUM- <br /> UM- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Nz5, <br /> (Complete in Triplicate) -p`_c 7 <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein derscribe 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 /> -.{� <br /> _A 5 7 A i t `� City.1L A-1 �- Lot Size/Acreage � �1 <br /> Job Address <br /> Owner's Name �i L r 1� Address @4� ` R� N �_ Phone <br /> �L v <br /> Contractor S-[A r s Ph <br /> License No. one <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION O Out of Service Well O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well L7 <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 /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C1 Domestic/Private O Gravel Pack O Tracy Type of Casing Specifications <br /> 1'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.1 I REPAIR/ADDITION I I DESTRUCTIONINo 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 soil 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 /> oo <br /> Distance to nearest: Well Foundation Property Line <br /> E <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <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 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 Californiq' <br /> The applic stc 1 or1nI required inspections. Complete drawing on reverse side. <br /> Signed X Title: no Date: <br /> 7- & <br /> IF USE ONLY <br /> c <br /> Application Accepted by 4w�13` <br /> Date T �� - Area �T <br /> Pit or Grout Inspection by Date 1 Final Inspection by Date <br /> Additional Comments: VIS IC17" <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 74UNT DUE AMOUNT REMITTEDH RECEIVED BY DATE PERMIT'NO. <br /> INFO CAS <br /> + EH 13-21IREV.1/NSI ��d� �� ID C' <br /> EH A-25r ` _O <br />