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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 BOR 2009, STOCKTON, CA 95201 <br /> HERMIT 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 /> apprication is made 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 /> t'] /�yyn <br /> Job Address 1..—o/2 V t:_ LrL 2- City Lot Size/Acreage <br /> Owner's Names ' Addr �- <br /> ess A �' 2 'l Phone <br /> Contractor. I ! Addressf �� F License No.W5 _Phone< � Z <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACE ENT ❑ DESTRUCTION D Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ " OTHER ❑ Monitoring Well <br /> _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LI S DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULT E VXLL OTHER WELL PITS/SUMPS <br /> a INTENDED USE TYPE OF WELL PROBAn <br /> STRUCTION SPECIFICATIONS 1 <br /> C] Industrial CJ Open Bottom El Manteca of Well Excavation Dia. of Well Casing <br /> fa Domestic/Private ❑ Gravel Pack El Trof Casing Specifications <br /> i <br /> I'1 Public 1-1 Other F1 Deth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eaace Seal Installed byRepair Work Done L] Type of Pump State Work DoneWell Destruction ❑ Well Diameter erial & Depth <br /> Depth Filler Material & Depth 9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,! REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is V I <br /> �4 vailable w in 200 at.) <br /> Installation will serve: Residence_�Commercial Other��— � r <br /> Number of living units: Number of Eedroom tI <br /> r • Character of soil to a depth of 3 feet: <br /> 'Water table depth <br /> F SEPTIC TANK., fi ❑ Type/MfgA, Capacity No. Compartments I <br /> PKG.. TREATMEI T PLT. 0 1 1 ,,,J Method ofDispo al <br /> . Distance to nearest: '1 Well /Foundation Property Line_.,[`` t <br /> LEACHING LINE D IN-, & Length-of lines otal length/size 26 ! <br /> FILTER,BED ❑ ,Distance to nearest: .. 1 Well Foundation Property Line r� <br /> v41 <br /> SEEPAGE PITS ti I I Depth 2 J Sire Number <br /> SUMPS Ll Distance to ne rest: Well -Foundation� Property Line ( V <br /> DISPOSAL PONDS El <br /> I hereby certify that Vhave�p�epared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules=and-egulations 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 or sub-contracting sigriature <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 applicant ust call Co require inspections. Complete drawing on reverse side. <br /> Signed X Title: - �.,. „ ' Date: <br /> * FOR PfPARTMENT USE ONLY ^� <br /> Application Accepted by rf� LDate YArAa AL� <br /> Por Grout Inspection by ate Final Inspection by Date l <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health H <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> INFO AMOUNT DVE AMOUNT REMITTED CASH CK RECEIVgO BY DATE PERMIT NO. <br /> + EH 13'24 IREV.t/H5i <br /> EH e1.28 <br />