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Ar <br /> APPLICATION FOR PERMIT 100 D` <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES I YEAR FRQM._PATE 1$SUED <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. �y <br /> S� 7�� <br /> Job Address Z63-5 S 0 City Lot Size/Acreage...,_ <br /> r <br /> Owner's Name r �df�+l�-S C/ Address Phone <br /> - CbContractor I� aAddress License No. Z Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (.1 Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing Specifications <br /> 1'1 Public I:1 Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I Irrigation Approx. Depth i I Eastern Surface Seat installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth --- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION RUCTION I I lNo septic system permitted if public sewer is (fJ <br /> � available within 200 feet.) <br /> Installation will serve: Residence`�Cammercial_^�Other <br /> Number of living units: —I— Number of bedrooms <br /> Character of soil to a depth of 3 feet: C Cat Water table depth <br /> SEPTIC TANK ❑ Type/Mfg } 1 Capacity No. Compartments <br /> PKG, TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE & Length of lines Total length/size Vvu <br /> FILTER BED ❑ Distance to nearest Well Equndation Property Line <br /> SEEPAGE PITS I I Depth Size Number ` <br /> SUMPS 1114—Birt nce to nearest:/+ Wq Foundation Property 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 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." 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 /> � of Calitornl _ � <br /> The applita ust allcr for aR>re iced ' 'on m`_ple swing on r verse side <br /> Signe Title: Date: <br /> - / <br /> R DEPARTMENT USE ONLY r <br /> Application Accepted by iL!A,� r"� ._ _ Date le, Area <br /> Pit or Grout Inspection by Date Final Inspection Date e:9 2- <br /> Additional <br /> Additional Comments: <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 /> INFO <br /> FEE AMO[`UNT DUE AM t/JiVT REMITTED ASH RECEIVED BY DATE PERMIT'NO <br /> Ole <br /> . EN1J24IREV.IiKsl <br /> EH 112e 1` I (rt0"0 i C [/ lJ i 0 <br />