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;,APPLICATION FOR PERMIT <br /> SAN JOAQUIN­COUNTY PUBLIC HEALTH SERVICES <br /> ENVIROTAL HEALTH DIVISION <br /> 1601 E HAZEL ON AVE. , PHONE (209)468 3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> k9MIT EXPIRES „1 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 /> h i <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address + ` Phone <br /> Contractor dress g cense No. Phone <br /> TYPE OF WEL /PUMP: NEW WELL ❑ 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 F.LO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELLt PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> n Industrial ❑ Open Bottom i ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s Specifications <br /> I'I Public la Other q n Delta Depth of Grout Seal y_ --.-,Type-of Grout <br /> I I Irrigation _.Approx, Depth t (-Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump ! H.P. State Work Done <br /> Well Destruction ❑ Well Diafneter 4 Sealing.Material &_Depth, w <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is <br /> available within 200 feet.] <br /> ,ter✓ <br /> Installation <br /> 5` on iivill serve: Residence_ Commercial— Other i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth <br /> -4- <br /> Character feet: ----.Water Water tbfe depth <br /> SEPTIC TANK. D TYP 9 Capacity <br /> -e/Mf Comp-airt' lc 1 <br /> ,+�J ments <br /> PKG. TREATMENT PLT. ❑ Na. CompaMethod of Disposal <br /> Distance to nearesti Wel -Foundationr_eProperty Line ZJ�2 � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation __J7KA Property Line _ <br /> SEEPAGE PITS 11 Depth Size Number 1 <br /> SUMPS " Ll Distance to nearest: Well I T Foundation W� Property Line 1 t r <br /> r;�M <br /> POSAL PONDS""'"�"'0— 'T"`- " <br /> 1 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 /> 4 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." Contractors 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 persona subject to workman's compensa- <br /> tion laws of California." s.. 1. <br /> The applicant mW call al uir s ctions. C p to drawing on reverse side. <br /> Signed K ?17- Title: C/-f'yC7 Date: <br /> L —a mFOR DEPARTMENT USE ONLY <br /> Application Accepted by -� , „ Date (�""'f���� �� Area <br /> GI <br /> t Grout Inspection J� �q Date —r r O Final Inspection by L1.f.�1 td--- pate <br /> Additional Comments: -e c�fG.,c.J _ V rtiC��.w-Q QCCe <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK III RECEIVED BY DATE E4PERMIT"NO.INFO fTn��..�IjC.ASHEH13.211REV.t/n5! Jr" � "�s _t <br /> EH 31.269] <br /> r <br />