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APPLICATION FOR PERMIT <br /> 4 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> } ENVIRONMENTAL HEALTH DIVISION <br /> X601 E. HAZELTON AVE. , PHONE (209)468-3420 <br />' P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT 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 cotnpliance with San Joaquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> i <br /> Job Address City S7-6Crt7b") Lot Size/Acreage <br /> Owner's Name 5—OA,-2_A L Address <br /> Phone <br /> Contractor Cf� A] r,�C/'Jn.�. / jjc� Address P-40. &1C V3. A� zi=;O License No. Phone f7a?Q <br /> TYPE OF WELL/PUMP: NEW WELL 0WELL REPLACEMENT C] 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 PITSISUMPS I <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 /> 'L1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 'I`l Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> (,i I Irrigation 'Approx. Depth I I Eastern Surface Seal Installed by <br /> 'Repair Work Done U Type of Pump gg H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth a _ <br /> Filler Material & Depth <br /> `TYPE OF-SEPT- 'WORK:..NEW INSTALLATION I I REPAIR/ADDITION NDESTRUCTION I 1 {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> x Installati6n will serve: Residence Commercial Other <br /> Number of living units: eNumber of bedrooms <br /> ''Character of soil to a depth of 3 feet: t Water table depth <br /> SEPTIC.TANK ❑Type/Mfg i = Capacit <br /> Y No. Compartments <br /> PKG. TREATMENT XP <br /> 1 C) Method of Disposal <br /> Distance to nearest: Wel! <br /> f . Foundation Property Line <br /> .` I <br /> LEACHING,LINE ft =L� No. & Length of lines Total length/size F <br /> FILTER BED r ❑ Distance to nearest: Well Foundation Property Line <br /> +� p Y F <br /> SEEPAGE PITS 11 Depth IY Size ! Number <br /> SUMPS Distance to nearest: Well_ Foundation /0/ J r1 <br /> DISPOSAL PONDS ❑ Property Line�T <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 befcome 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 /> y tion laws of California." <br /> The'applicant must call forI required.inspect' ions.Complete drawing on reverse side, <br /> Signed x` -`tom <br /> Date: <br /> ' O EiLMENT USE ONLY <br /> Application Accepted byft <br /> Lf <br /> Date 9 <br /> tDate b <br /> Pit or Grout Inspection by �` Date Final Inspection by -2.1"w (� <br /> Additional Comments: } <br /> Applicant _ Return all copies to: San Joaquin County Public Health <br /> Services, Environmental health Permit/Services <br /> 7 1601 E.-,Hazelton Ave., P o 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CK RECEIVED By DATE PERMIT'NO. <br /> . EH 7344{AEY.iinsr �V353 <br /> R ,} �]/�EH 1426 1 ATM"/ V INC <br />