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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 /> Il EXP IRES 1 YEAR FROM DAIg 15PUED s <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This <br /> applics.tion is made in Compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 1 <br /> Joaquin County PublicHeal h Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name �� � Raaress � ! -- Phone 5W��g <br /> Contractor _ __Address ��<� �'�-- - _. License No;Z3��/C) Phone6993Z: � <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 <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 PITS/SUMPS .� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> V] Public i-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> r I Ifrigation _.Approx. Depth I 1 Eastern Surface Seal Installed,by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION ( I DESTRUCTION 4P lNo septic system permitted if public sewer is <br /> available within 200 feet.l <br /> Installation will serve: Residence_b4 Commercial___— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: 4 LeWater table depth <br /> SEPTIC TANK. ❑ Type/Mfg t /C Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ f Method of Disposal <br /> Distance to nearest: Well [�_ Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Z4 Property Line <br /> SEEPAGE PITS I I - Depth Size Number <br /> SUMPS Ll Distance to nearest: Well 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 of 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 /> tion laws of California," <br /> The applica m t call for all required ins Ctio s. Complete drawing on reverse side, <br /> Signed X_ � � ���� Title: Date: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by K p DateArea <br /> Pit or Grout Inspection byFinal Inspection by Date 6 P <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REM177ED ���"r1) RECEIVED BY DATES P/E�RMIT"NO. <br /> + EN13.24rREV.Iie91 ��� �~`j(�`�0 <br /> EH',4.25 <br />