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4�,�J D APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FROM DAZE, 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 Public Health Services. <br /> r <br /> Job Address ' City Lot Size/Acreage <br /> Owner's Namd.,��� v � Tess - � �dgNj� _ Phone <br /> Contractor .,L!! Phori . <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑{ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ MonitoringrWell ❑ <br /> DISTANCE TO NEARESTr SEPTIC TANK SEWER LINES j DISPOSAL FLD! PROP. LINE <br /> FOUNDATION..^_ __- _ AGRICULTURE WELL OTHER WELL PITS/SUMPS. <br /> i <br /> INTENDED USE TYPE OF-WELL I-PROSLEM.AREA CONSTRUCTION SPECIFICATIONS <br /> �f I <br /> Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [1 Domestic/Private Cl Gravel Pack Cl Tracy Type of Casing Specifications <br /> i'l Public is Other rl Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation —Approx. Depth 13 Eastern Surface Seal Instailed by <br /> Repair Work Done L7 Type of Pump H,P. State Work Hone <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth " \ <br /> Depth Filler Material & Depth $ d 11 <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION i I INo septic system permitted-if public sower is V <br /> available within 200 feet.l 4 <br /> installation will serve, Residence— Commercial )<, O Ther <br /> Number of living units: N A Number of bedrooms � O`, <br /> Character of soil to a depth of 3 feet:._ _rf �1F�r� -_ ', —Water table depthI.V r <br /> SEPTIC TANK.AFJ-_:0'. O Type/Mfg f Capacity"" No. Compartments} <br /> PKG. TREATMENT PLT. ❑ Y j ' <br /> Method of Disposals <br /> Distance to nearest: Well Foundation Property Line s `� <br /> LEACHING LINE ,0, No. & Length of lines . �...,„ ✓- Total length/size '. t” _ <br /> `FILTER BED ❑ Distance to nearest: Well hkIVE' Foundation r 4 - Property Line <br /> SEEPAGE PITS Pof, Depth P-157 Sire - Number <br /> SUMPS Ll .Distance to nearest: WeIILIE' Foundation - s Property Line ' 4 <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 Nr <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following:i'I certify that in the p�erlormance 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 stb&contr`acting signature <br /> certifies the following: "I Certify that iri 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."- sy, <br /> t <br /> The applicant mut call for all requir, d in ctionst Ca ete drwing verse side. _� f <br /> Signe Title: Date: . ° <br /> EQELDEPARTMENT USE ONLY - �1 _ <br /> Application Accepted by Date - ��� Area <br /> t L � W, . <br /> Pit or Grout Inspection by Date I _. Final_Ii.ispection.by— � r��r Date <br /> Additional Comments: ! <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services \ ff <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> IFEE NFO AMOUNT DUE AMOUNT REMITTED CK CASK s_ RECEIVED BY DATE PEAMIT'NO. <br /> EH 3-24 <br /> + EH 114-20 IAEV. <br /> � J I <br />