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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 BOX2009, STOCKTON, CA 95201 <br /> ENMIT 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. <br /> / <br /> Job Address _ km-(rf�l.._/_ l� City Lot Size/Acreage <br /> Owner's Name Address►' _' ,xQ���kl &-y`y Pho✓n`e ,n <br /> ConIra ct6 Address License No. j P h o n OU <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ t of Service Wel <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHE - Monitoring Well C7 <br /> f <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 /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> a <br /> [I Domestic/Private ❑ Gravel Pack El Tracy _ Type of Casing Specifications <br /> < I'I Public Cl Other 11 Delta Depth of Grout Seal Type of Grout <br /> I Irrigation Approxi Depth I I Eastern; Surface Seal Installed by <br /> Repair Work Done .U Type�Diam <br /> ump -- • K.P. State Work Dona <br /> Well Destruction ❑ Well � •Sealing Material & Depth <br /> Dept ' '•�,` Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.`I I,- IR/ADDITION I I DESTRUCTION I ] INo septic system permitted if public sewer is <br /> { available within 200 feet.) <br /> Installation will serve: Residence f Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:' Water table depth ! <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> Distance to nearest: Well Foundation Pr rty Line <br /> L RING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Wall Foundation Property Line <br /> � 1 <br /> SEEPAGE PITS 11 Depth Size Number ° <br /> SUMPS D Distance to nearest: well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <br /> I hereby certify that I have prepared this application and'that the work will-b'e done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquiri 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 workmen'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." t <br /> The applicant must call for all wired in ctions. Complete drawing an reverse side. <br /> Signed <br /> 8 - Title. =-ti ter, � $�1 C-tr- Date: <br /> 1���EPART��ENTUSE ONLY 7 <br /> Application Accepted by �] Date S Area <br /> Pit or Grout Inspection by Date Final Inspection by p81e .�' d"q <br /> i <br /> Additional Comments: N,- - ; , <br /> Applicant - Return all copies to: San Joaquin County Public •Health <br /> i Services, Environmental Health Permit/Services <br /> Qb 160 a ton Ave..,_p O-Box..2009, Stockton,.-CA.-.95201-4 <br /> fEE AMOUNT DUE A NT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'N0. <br /> t - <br /> /�(', <br /> EH t3-24IAFV.J/q51 <br /> EH 14.26 � [ -r <br />