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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 BOX 2009, STOCKTON, CA 95201 <br /> MWIT_-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 trade 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 /> Job Address 4 3 O,eJ5� /—/ _— City Lot Size/Acreage <br /> Owner's Name IJ ___-/4 AC 11C Address .Gh w Phone <br /> Contractor�v�af4Address License No. Phone - e/ <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C- DESTRUCTION ❑ Out of Service Well C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation pia, of Well Casing <br /> F� Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI 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 Yype of Pump H.P. State Work Done, <br /> Well Destruction. _13 Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I .(No septic system permittedifpublic sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_�K 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 /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE X No. & Length of lines A /u a Total length/size <br /> - <br /> FILTER BED C7 Distance to nearest: Well CALAfids Fou dation �u Property Line /0' <br /> �S <br /> , ., <br /> SEEPAGE PITS [ I Depth Size Number <br /> SUMPS I_I Distance-to nearest: Well Foundation— Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, 1 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, l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: �� Date: 117. g' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by -71'1011Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ate <br /> Additional Comments: <br /> Applicant'- Return all copies to: Sam Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK t RECEIVED-BV— DATE PERMIT'NO. <br /> . EH1 -24{NEV.tiHSl <br /> EH 1 <br /> 4-16 ]r f <br />