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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY P�C HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH HEALTH DIVISION <br /> 1601 E. <br /> HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> C.tir.rT►� Ple POS G PERMIT EXPIRES- 1 YEAR k01LATE I.I$SUED- <br /> 11 (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 /> r <br /> Job Address 1 0.4 City Lot Sire/Acreage <br /> r Address S— Phone <br /> Owner's Na _ <br /> Contractor Address25�7 A�<J�A&A-e License No� 16 Phone <br /> TYPE OF WELL/PUMP: NEW WELLI`❑ t WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION,❑ SYSTEM REPAIR OTHER O Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; �" DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �OTHERtWELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA- CONSTRUCTION"SPECIFICATIONS'y <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ?Kbomestic/Private 111 Gravel Pack D Tracy Type of Casing Specifications <br /> ('I Public fa Other n Delta Depth of Grout Seal Type of Grout <br /> I Irrigation —.Approx. Depth I 1 Eastern Surface Seal installed by (� <br /> Repair Work Done .,f Type of Pump 5�KAJ10' H.P. State Work Done <br /> Sealing Material &,Depth <br /> Well Destruction ❑ Well Diameterk. <br /> y' <br /> Depth j'E Filler Material &_Depth,' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I-INo septic systerl'i.:permitled if public'seawer is <br /> ;t available within 200 feet.], <br /> installation will serve: "Residence T,.—, 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. ❑ f5 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines -Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation"` t Property Line ' <br /> ' <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation f Property Line <br /> DISPOSAL PONDS D i <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, an <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 no <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signatur <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 workmancompensa- <br /> tion laws of California." <br /> The applic t all for all requ" d insPections. Complete drawing on r e side. <br /> Signed Z Title: Date: <br /> tl R ARTMENT USE ONLY <br /> Application Accepted by -�" Date <br /> Z' Ar a <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, EnvironmentalHealthPermit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> WRgE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> CASHEH 13'24 1HEV.r i H 51EH 1420 <br />