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APPLICATION FOR PERMIT ` 00 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RES 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 CountyPublicPublic Health Services. If.- A 4 <br /> Job Address _`` 7 Sr city Got Size/Acreage C, I <br /> Owner's Name �� <br /> 4L Address a m� Phone r <br /> 17t�F License Nt>����PS PhOne�3V; y71x <br /> Contractor�l�^� �s Address r"d <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> ti Monitoring Well ❑ <br /> PUMP INSTALLATION'W SYSTEM•REPAIR ❑�� OTHER D /I <br /> DISTANCE TO_NEAREST: -SEPTIC,TANK_1L,�� SEWER_LINES_ _ w. DISP'OSAL FLD. PROP. LINE CIS <br /> AGRICULTURE WELL OTHER,WEtl. "PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial O Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'DomesticlPrivate1 Gravel Tracy Type of Casing 00V<- Specifications <br /> i"1 Public !1 Other n Delta 1 Depth of Grout Seal Type of Grout <br /> C J7tC�.+ <br /> t I lftigation 'Lts�Approx. Depth. 11 Eastern Surface Seal Installed by h 12AL n 1 <br /> 1.V ! H. State Work Done r7 � �J <br /> Repair Work Done U Type of pump -- t /y <br /> Well Destruction ❑ Well Diameter i Sealing Material & Depth �J j <br /> Depth i I Filler Material 3 Depth ( /� <br /> TYPE OF SEPTIC W04-K--. NEW INSTALLATION-1.1 ..-'REPAIR ADDITION i I DESTRUCTION I I lNo septic system permitted if public sewer is v �I <br /> available within 200 feet. r (� <br /> Installation will serve: Residence-N Commercial. Other t V 1 <br /> Number of living units: Number,of bedrooms y la <br /> Character of soil to a depth of 3 feet: 4 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg " Capacity No. Compartments <br /> PKG. TREATMENT PLT. 03 j { Method of Disposal �^ <br /> •Distance to,,nearest: Well Foundation Property Line <br /> 1 <br /> LEACHING SINE 0No. & Length of lines Total length/size <br /> , <br /> FILTER BED ti1 0 Distance to nearest: Well Foundation Property Line t <br /> t,• f <br /> SEEPAGE PITS ' �� 'i I Depth Sire"- Number <br /> SUMPS ��• ? Ll,. Distance to,nearest: Welt 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 i <br /> �a � <br /> Home owner or licensed agent's signature certifies the following: '9 cert"fy 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%,compensation laws of California." Contractor's hiring or subcontracting signature <br /> s 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." v" <br /> W* <br /> The applicant must call for all r quired inspections. Complete drawing-on reverse side, <br /> t <br /> Signed X �fe�- Title: "f "n~ - _ Date: `�` <br /> � � I r <br /> OR DEPAR MENT USE ONLY <br /> I Application Accepted by If Date —� Area '� <br /> Pit or Grout Inspection by Date Final Inspection by Date`- <br /> Additional Comments: G <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 /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO F I 1 <br /> t `'X �7 <br /> . EH 13-24 CAW 5) ,Q© -`-'— gL41 <br /> I EH.4.2a <br />