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W <br /> APPLICATION FOR PERMIT <br /> - v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 4 99 t '1601 E. HAZELTON AVE. ; PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PENIT- EXPIRES- 1 YEAR FROM DATE I.SSUED <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 6$ and the Rules and Regulations of San <br /> Joaquin County Public Health Services. : i <br /> Job Address City Lot Size/Acreage <br /> Owner's Name riNCi�,w°iYY1dress 1 r f ��' Phone <br /> Ile <br /> i <br /> Contractor 4 dress ense No. Phone <br /> TYPE OF WELL PUM : NEW ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 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 /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i C.l Domestic/Private C) Gravel Pack 0 Tracy Type of Casing Specifications <br /> Cl Public [I Other i-1 Delta Depth of Grout Seal Type of Grout-- <br /> i I Irrigation ­Approx. Depth t 1 Eastern Surface Saul Installed by <br /> Repair Work Done' El Type of Purrtp H.P. State Work Done yam' <br /> Well Destruction ❑ Well Diameter Baling Material & Depth <br /> 1ZiZ <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC.-WORK: NEW INSTALLATION IFI REPAIRlAODITION I I DESTRUCTION I I INo septic system permitted if'plrblic sewer is <br /> ' available within 200 feet,) <br /> Installation will se e:, Residence! Commercial Other <br /> Number of living units: Number of bedrooms <br /> I Character of soil to a depth of 3 feet: ~� a Water table depth <br /> SEPTIC TANK. O Type/Mfg CapacityNo:7Compartments, <br /> PKG. TREATMENT PLT. ❑ !� ;� i Method of Disposal <br /> Distance to nearest: Well D Foundation Property-Line- <br /> /� <br /> y V <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> k i FILTER BED C] Distance to nearest: Well FoundationProperty Line <br /> EEPAGE P <br /> 11 Depth Size LZ 97 Number <br /> SUM 0 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 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 California." <br /> The applicant ust_gAl for all equ inspection omplate drawing on r ids. <br /> I <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY ` <br /> ���Application Accepted by Date G Area <br /> 01 <br /> —y <br /> f Pi or Grout Inspection by a ( nal lnspection by be <br /> Additional Comments: ��}✓1�L/� ��'t�1!.C4/Y LCJ�rfT Y�� 1 t r JC ci-P _i <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services/ <br /> s 1601 E. Hazelton Ave., P 0 Sox 2009, Stockton, CA 95201 <br /> IFEE MOUNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY l DATE PERMIT'NO. <br /> i <br /> EH <br /> 13,24(REV.iixs1 <br /> E <br /> k <br />