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I J <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQ�IN COUNTY PUBLIC HEALTH SERVICE <br /> I ENVIRONMENTAL HEALTH DIVISION 0 � <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 n n <br /> M() C, ( J <br /> EXPIRES 1 YEAR FROM DA E ED <br /> r (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 /> f application is made in comp'lianci with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> )) Joaquin County Public Health Services. <br /> 1--li rb Address /�� i�il�. <br /> /( .City Lot Size/Acreage <br /> Owner's Name Y+ c d >7L+ alt gddress <br /> Phone .3`--9/ <br /> �-Contractor S �s �!c Address Lelc License No. Phone S`— <br /> TYPE OF WELL/PUMP; NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION C7 Out of Service Well Cl <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C] 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 /> C-} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F1 Domestic/Private Cl Gravel Pack C1 Tracy Type of Casing Specifications <br /> I"1 Public i-1 Other 1 1-1 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 H.P. <br /> State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDIIPUN I I DESTRUCTIO INo septic system permitted if public sewer is _ 1 <br /> ailable within 200 feet.I <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Numb,r of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. i Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT. 0 Capacity No. Compartments <br /> Method of Disposal <br /> Distance to;I nearest: Well Foundation Property Line <br /> �. k <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED CJ Distance to nearest: Well Foundation <br /> � Property Line <br /> SEEPAGE PITS 11 Depth Size _ <br /> SUMPS Number <br /> Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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, t <br /> rules and regulations of the San Joaquin County and <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 /> 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 /> II <br /> certifies the following: "I certify that in the pemtoerformance of the work for which this permit is issued, l shall <br /> tion laws of California." it employ persons subject to workman's compensa- <br /> The applicant ust call for flq required inspe ions. Complete drawing on reverse side. <br /> Signed X Titlera.oti, Datl <br /> 71 ORD PARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments.- <br /> Applicant <br /> omments: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 MDUNT ptJE AMOUNT REMITTEDCK <br /> INFO C H RECEIVED BY DATE PERMIT'NO. <br /> t <br />