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APPLICATION FOR PERMIT <br /> 10 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED <br /> (Complete in Triplicate) <br /> i <br /> C 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. 119 and 1862 and the Rules and Regulations of San <br /> I Joaquin County Public Health Seryices. <br /> Job Address K//J,,1 City Lot Size/Acreage <br /> 13 <br />} Owner's Name Address Phone <br /> Contract w Address 0 �W r License No. .Z Z to Phone f Q <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Nlonitorng 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 /> El Industrial ❑ Open Bottom '- D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C:1 <br /> Domestic/Private, D Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public El Other fl Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation — Approx. Depth' I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth ` ller Material & Depth W <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAI ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: Residence P/ Commercial_ Other <br /> Number of living units: J_ Number of ooms � - { <br /> Character of soil to a depth of 3 feet: Water table depth Q t \ <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 Method of Disposal V <br /> Distance to nearest: Well Foundation Property Line F T <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ff <br /> • r r <br /> FILTER BED CJ Distance to nearest. Weil Foundation Property Lina <br /> 1• !/ <br /> SEEPAGE PITS Depth Size Number. <br /> # SUMPS Ll Distance to nearest:; "-INeq/ G Foundation iProperty 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 4certifies the following: "I'certify that in the-performance-of•the wofk 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 compansa- <br /> tion laws of California.' - - -^�^'--__ •� <br /> i The applicant st call for quir d inspections.'Complete drawing on reverse�i� <br /> Signed X Title: r Date' ZQ <br /> r � r , <br /> t1 FOR DEPARTMENT USE ONLY <br /> Application Accepted by�^ DateArea �� <br /> or Grout Inspection by Date Final Inspection byr�'`�-�4t _ Data .� rG <br /> I <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services 1 <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> r <br /> FEECK I <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY l OATS PERMIT NO. <br /> {F + trtEv.+/K5i <br /> EH f4.t6 �✓'�� C7• O-D <br />