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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 0 BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES ] YEAR FROM DATE ED I <br /> �, r,� &"64 <br /> 41"6 �'L (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 /> I application is made in campliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job AddressR40 City_ Lot Size/Acreage <br /> Owner's Name _ _/� / Address <- T 1 p one <br /> Contractor �ddress 1 License No. Phone � <br /> TYPE OF WELL/PUMP: N19W WELL WELL REPLACEMENT C� DESTR CTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ �/(�1�7OTMER ❑ Monitoring Yell <br /> / L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK I,P SEWER LINES �"- DISPOSAL FLO. PROP, LINE <br /> FOLINDATION - E _ AGRICULTURE WELL rr l <br /> THER WELL �� PITS�5UIWfPS <br /> INTENDED USE i TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 0 !/ Qt <br /> omesticlPrivateGravel Pack L� Tracy Type of Casing <br /> ng G Specifications (� <br /> '1 Public ,Fl other iut <br /> r <br /> �I Delta Depth of Grout Seal � Type of Gro � 1 <br /> i I Irrigation Approx. Depth I I Eastern rS rface Seal Installed by cldL .f <br /> Repair Work Done LJ Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted it public sewer is <br /> �- <br /> installationavailable within 200 feet.) <br /> will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms ,r t <br /> Character of soil to a depth of 3 feet; Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg <br /> Capacity-' <br /> No. ComparPKG. TREATMENT PLT. .1 rtments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ,❑ iNo,A Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS <br /> 11 Depth--£-- Size Number ' <br /> SUMPS ` ' t <br /> LL I Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS p i! �.`� �� e <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 Californi" C ' <br /> certifies the fallowing; "I certify that in the performance of the work for which this permit is issueda. ontractors hiring or sub-contracting signature <br /> 'laws of California." <br /> , I shall employ persons subject to workman's compensa- <br /> rion , <br /> The ap Iicant" II a uir = <br /> E , q Comptifie drawing on rev r e: <br /> Signed X <br /> itie: <br /> _ _F OR_DEPARTMENT_JSE.QNL . <br /> '�• i ( 1 <br /> Application Accepted by <br /> Date Atrea ' <br /> Pit or Grout Inspection by ,Zp l ¢y4/ I 3 <br /> �Da-` Final Inspection <br /> Date <br /> r Additional Comments: <br /> Applicant - Return all copies to: San Joaquin Co ty Public Health l <br /> Services, Environmental Health P..ermit/Servicea i <br /> + 1601;8:`�Hazelton Ave s;':P. D�Eax'2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED By OATE PERMIT'NO. <br /> EH 144.2 <br /> EH 1 )REV,riesi <br /> .26 t t�o _�']� — r <br />