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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION i <br /> 1601 E. HAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOR 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ISSED <br /> (Complete in Triplicate) <br /> Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application 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 <br /> Job Address City�&A' Lot Size/Acreage <br /> f � <br /> Owner's Name r <br /> � ,, �!�(LG ! rj - Address S Phone I <br /> �� ' <br /> Contractor <br /> ! • ` `G/t'4 Address- IVZI & License Now Phone <br /> TYPE OF WELL/PUMP: r '• NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of,,Service Well Cl <br /> Mo[iitoring Well C] <br /> [PUMP INSTALLATION Cl SYSTEM REPAIR Cl•- OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DlSP05AL FLD. PROP. LINE <br /> I = FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS <br /> 5 INTENDED USE TYPE OF WELL PROBLEM AREACONSTRUCTION SPECIFICATIONS: I <br /> I Ci Industrial Y❑ Open Bottom 0 Manteca Oil of Well @xcavation Ria. of Well Casing <br />' Cl Domestic/Private ;L1 Gravel Pack 11 Tracy! Tyr6'of,,.C�asing # Specifications4 <br /> k" Type of Grout <br /> I'i Public it-� Other n Delta� Depth bf Grout Seal � I , <br />` I } Irrigation i _.Approx. Depth I 1 Eastern Surface Seal{Installediby <br /> 4 1 State Work gone: 1 <br /> Repair Work Done U Type of Pump t H.P. . <br /> 4 <br /> Sealing Material & Depth 1 Well Destruction ❑ II <br /> Diameter Well i <br /> Depth _.... �.w. �` ^A� Filler Materiel & Depth <br /> { <br /> TYPE OF SEPTIC WORK:1 NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if!putilic sewer is <br /> available within 200 feet.1 I 5 <br /> Installation will serve: R s deuce A'f Commercial- Other <br /> i <br /> Number of living units: Number of bedrooms ° ? <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK O TypeyMfg, L - _— Capacity No. Compartments <br /> PKG. TREATMENT PLT. CI ` r � I �`�' µMeihodiof Disposal { <br /> W ;l?ra ert Line <br /> Distance to nearest:, ell- Foundation p Y <br /> LEACH4NG LINE i No. & Length of Eines - Y ^p` ' ��,T-oral length/size Q i t - <br /> ILTER BED ` Cl Distance to nearest. WellFoundation Property Cine <br /> ^SEEPAGE PITS l'I Depth Size I r - Number 1 <br /> SUMPS 0Distance to nearest: Well" Foundatiofi Property Line <br /> DISPOSAL PONDS 0,-- <br /> I hereby certify that I have prepa"red ibis application and that the work will be done in accordance vVith San Joaquin"county ordinances,"state laws, and . <br /> rules and regulations of the San Joaquin County i <br /> Home owner or.licensed agent's signature certifies the following; "I certify that in"the performance of the worlClor,which this permit is issued, I shall not <br /> employ any person ins4th tr►annar as to become subject to workman's compensa`tlon laws of California." Contractor's hiring or subcontracting signature <br /> certifies the followi : I certify that in the performance of the worklo' r which this'permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California,'.- <br /> The applicant must call for':al squired speevon . Complete drawing on reverse side. i ,,'• i <br /> Signed X Title: Date~$ <br /> t <br /> i• r �� cy, FOR DEPARTMENT'USE ONLY <br /> h: <br /> l / F Area_sC� <br /> " Application Accepted by Date rr <br /> Pk or Grout Inspection by Date �<: Filial•Inspection b Da <br /> te <br /> Comments:. r ;r <br /> AdditionalI <br /> Applicant - return all copies to- San Joaquin County PublicrHealth t 1 j <br /> ' ? Services, Environmental.Health Permit/Services <br /> j 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201" € <br /> "< 'FEE AMOUNT DUE AMOUNT REMITTED 4CK 8 RECEIVED'BY DATE PERMIT'�4Nj <br /> ,,INFO CASH r_M"- y - - <br /> REV <br /> ::d <br /> } �� ,�_.�•� .. --.r. /CZ/ <br /> 1 C; <br /> EH i�•26 r C <br />