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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7i <br /> it ENVIRONMENTAL HEALTH DIVISION <br /> 1601. E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PER1[IT EXPIRES 1 YEAR FROM DATE 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. / �I <br /> Job Address t2 ' < u - Pe, City Lot Size/Acreage <br /> Owner's Name ��� 'y -5 _ Address Phone <br /> Contractor z6v Address - _—License tufo.�Fhon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] OTHER ❑ Monitoring Well €� <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 /> f_-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N Domestic/Private ❑ Gravel Pack El Tracy Type of Casing Specifications <br /> Il Public f_1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth y ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAiR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ' <br /> available within 200 feet.) <br /> Installation will serve: Residence `� Commercial_ Other <br /> Number of living units: __/_ Number of <br /> Character of soil to a depth of 3 feet: �� a Water table depth <br /> SEPTIC TANK I, Type/Mfg Capacity No. Compartments 2 <br /> PKG. TREATMENT PLT. ❑ ! r Method of Disposal <br /> Distance to nearest: Well /05' Foundation-1 O Property Line &o) <br /> LEACHING'LINE R-'�No. & length of lines 0 Total length/sizer <br /> FILTER BEDS n Distance to nearest: Well X11 N1 Foundation 2S' Property Line <br /> SEEPAGE PITS W Depth 22-'F. I Size G Number- <br /> SUMPS LI Distance to nearest: Well �S�/ Foundation (v5 Property line <br /> DISPOSAL PONDS' © <br /> I hereby certify that I have prepared this application andEthat the work will be-done-in accordance with San Joaquin county ordinances, state-laws, and <br /> i rules and regulations of the San Joaquin County ,ti _,E­_- I? .. 11i — <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, l 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 applicaaLmust call for al req ed inspections. Complete drawing on <br /> j , r reverse side. <br /> Signed X, <br /> D DTitle: oe <br /> I f ` <br /> FO EPART _USE ONLY....- .r - <br /> Application Accepted by Date � CD AArea 01 <br /> It <br /> or Grout Inspection by Oate e - `final Inspection by / - � #/J ! Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> r Services,-Environmental Health-Permit/Servi56s— <br /> t 1601 E. Hazelton Ave., P 0 Box 2009,` Stockton, CA 95201 <br /> FEE OUNT DUE AYOUNT REMITTED CK RECEIVED BY DATE PERMI7'IVO. <br /> INFCr, CASH <br /> r EH 13.24 IREV.1 HSI �-.t✓ v ��� 3 U'�� d a `r.N `�� SCJ <br /> EK U-26 <br /> I <br />