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APPLICATION FOR PERMIT <br /> 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' <br /> A1ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIREg i YEAR FROM DATEASSUBP <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 Public Health Services. / ! <br /> Jab Address City <br /> `1��� / Lot Size/Acreagd � <br /> _._ <br /> Owner's Name T,&'4\0 —_— Address _n Phone <br /> m. C <br /> Contractor Address + hof`r License No��_—Phoney✓ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUC71ON ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> Cl Ind"ustriat­ ❑ Open.Bottom-' ❑ Manteca • Dia. of Well-Excavation,---',-.- - Dia.,�gf Well Casing <br /> Ca <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' <br /> I'1 Public 1-1 Other` F1 Delta Depth of Grout Seal Type of..Grout m <br /> I I Irrigation Approx. Doth I Eastern Surfs Seal Installed by <br /> Repair Work Done U Type of Pump , _ H.P. State Work Done 4 t1 j <br /> Well Destruction ❑ Well Diameter Sealing !fate ial & Depth 1_94 e %, r C l ac( ' <br /> Depth Filler Material & Depth U.41 SI�.S *tPlo a 051 I <br /> I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIRIADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> va,IabI4 ithln 200 feet.) <br /> Installation will serve: •Residence's Commercial_ Other `"e=rt SF6r /`j`f <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 /> 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 Property Line <br /> I <br /> SEEPAGE PITS I I Depth: Size Number <br /> SUMPS E1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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 son in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the owing: "I ertify that in the pe r ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws o alifornia." <br /> The applic n must call r a rns Ions. Complete drawing on reverse side. <br /> Signed Title: Date: r <br /> r <br /> DR DEPARTMENQ USE ONLY <br /> Application Accepted by J`r_-0c"n rine. Date Area <br /> �.�..s .:._ .._.-._ <br /> Pit or'Gromlt Intipectiori by- bate_ 'Final Inspection by Date f <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave.. P 0 Pox 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> . EHe8-2,tREV.i,NslZ3Cm � s- zi <br /> EH 1426 <br />