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G APPLICATION-,FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 21601 E. HAZELTON AVE. , PHONE (209)465-3420 <br /> X (9S P O BOX 2009, STOCKTON, CA 95201 <br /> V41 <br /> MIRES 1 YEAR FROM DA <br /> PERMIT I , •_ ,IE 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 1862 and the Rules and Regulations of San <br /> Joaquin County PublicHealth Services. <br /> Job Address �CV' ityIOL—F Lot Size/Acreage <br /> r ti` <br /> Owner's Name 1A a i" �. Address �G "'�" � __-___-_-__ Phone <br /> Contractor Ar Address ( O"`License No:, hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ;,DESTRUCTION D Out of Service Well ❑ <br /> PUMP INSTALLATION^ SYSTEM REPAIR X OTHER ❑ Monitoring well ❑ <br /> DISTANCE TO NEAREST:'SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Tpomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public t [I10ther ❑ Delta Depth of Grout Seal Type of Grout <br /> )k*6gation Approx. Depth I I Eastern S411 <br /> e Seal Installed by <br /> Repair Work-Done , Type of Pump ft� H.P. State Work Don e <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth's <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted it public sewer is J <br /> available within 200 feet.► <br /> i Installation will serve:. ,Residence_ Commercial— Other j <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 .y <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I <br /> FILTER BED ElDistance to nearest: Well Foundation Property Line , -1 ' <br /> t <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line . <br /> DISPOSAL PONDS 0 . <br /> I hereby certify that.l-havti�pmpared this application•'arid that the work will be done in accordance with San Joaquin county ordinances,state laws, and <br /> rules and regulations of the San Joaquin Cdimt_y <br /> Home owner or licensed a"ant's signature certifies the-following: ':'l 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 si naturq <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workme 's co pensa� <br /> tion laws of Ca' <br /> The ant must II for all require spect' s. C�plate drawing on re side. <br /> 1 Signed X f Title: - _„ Date: <br /> •*4 . OR_ PARTFV ENT USE ONLY �y <br /> Application Accepted by A Dare ` Area ' <br /> t M <br /> Pit or Grout Inspection by ` Date Final Inspection by - Date <br /> Additional Comments: S <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 /> k <br /> FEE <br /> I^NFOAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. <br /> EH$3-24[REV.IIK si <br /> EH 14.20 <br />