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APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES (9' <br /> ' ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ]PEMIT EXPIRES 1 YEAR FROM DATE 195UED <br /> (Complete in Triplicate) <br /> Application is hereby glade to San;Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in complisnce!uith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> F. <br /> — Lot Size/Acreage /+s <br /> Job Address City <br /> Owner's Namseas Address Phone I� <br /> /e� <br /> ( d� t Address_ License No.-3d Phone <br /> Contractor <br /> '� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 /> E71 Industrial C,1Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications j <br /> Cl Domestic/Private ❑ Gravel Pack. C] Tracy YP <br /> Irl Public 1-1 Other 1 n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth l I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Sealing Material Depth <br /> Well Destruction ❑ Well Diameter & <br /> Depth Filler Material b Depth <br /> T_YPE OF SEPTIC WORK: NEW INSTALLATION I -REPAIR IADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence Commercial_ Other � 1 <br /> Number of living units: _y_ Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water labia depth AW 7 Y <br /> SEPTIC TANK. ffl- Type/Mfg'( CapacityZZ DLJ _ No. Compartments 7- <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance to nearest: Well/jgLV 1 Foundation Property Line -20 <br /> i� <br /> LEACHING LINE Pr No. & Length of lines -� �d Total length/size 20 f <br /> (t <br /> FILTER BED ❑ Distance to nearest: Well Foundation /d Property Line <br /> r �4 w <br /> SEEPAGE PITS til`-•Depth a� Size Number - - <br /> SUMPS Ll Distance to nearest: wella260 Foundation r Property Line -201 <br /> I DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and thai'.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 /> r., Tr- <br /> Home.owner or licensed agent's signature certifies the fallowing:,"I`certity'that in the,performance of the work for which this permit is issued, I shall not <br /> l employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's(tiring 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 must calf for al squired inspections. Complete drawing on reverse side. O <br /> SignedTitle: Gt1�N �° Date: �� 9 <br /> '�—..._•.� . <br /> FOR DEPARTMENT USEONLY <br /> Application Accepted by Date Area J 2- <br /> I (jR�or Grout Inspection by t Date nal Inspection•by <br /> Addhionai Comments: <br /> Applicant - Return all copies to. San Joaquin County Public Health. _ <br /> Services, Environfaen"tal Health Permit/Serviaee <br /> _. 1601 E. Hazelton Ave.. P 0_Box.2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMI7'NO. } <br /> ' INFO �y ' �7� �//� rl �..f ]Il., /� r7-�� ���...-----� <br /> a EM 13-24IREV.tin5l 1 D � � (� V� v "'" r —r `-'�O `-�~��1./ <br /> iii EH 44.26 ! v <br />