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a <br /> I' APPLICATION FQR PERMIT <br /> i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$--3420 <br /> n �Q na U P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUBD <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 made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address _T,� City Lot Size/Acreage <br /> Owner's Name Xch- ft.e i _ Address 6&_ e _ __ _ _ _ Phone <br /> Contra clor!!! ic7 .I�_�_/ L. Address i2Y-7 NL of ��CY0�q License N Phone a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well [3 <br /> DISTANCE TO NEAREST: SEPTIC TALK 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 /> Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing Specifications <br /> I'] Public is Other rl Delta., -., Depth of Grout Seal Type of Grout <br /> I I irrigation w _`'Approx. De tp h A` 1 Eastern ^4, Surf a SeaE Installed by W <br /> Repair Work Done- (9 =Type of Pump arc] H.P. �' °State Work Done e, <br /> Well Destruction ❑ Well Diameter Sealing Material d< Depth <br /> Depth T —Fit ei Material & Depth � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I DESTRUCTION I ) INo septic system permitted if public sewer is {� 1 <br /> available within 200 feet.) <br /> Installation will serve: Residence 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 ❑ No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: -Well, _Foundation _ Property Line V <br /> SEEPAGE PITS It Depth - ^`Site, '�`�.� Number <br /> SUMPS D Distance to nearest Well At Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> If f 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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applies t for all required-i tions omplete drawing onse side. <br /> Signed Tilia: Date: <br /> FOR_ZLZ7� PARTMENT USE ONLY <br /> Application Accepted by Date Z_l Area <br /> Pit or Grout Inspection by Date Final Inspection by-5Date�� <br /> Additional Comments: r <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 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMITNO. <br /> a EH 13-24 IREV. <br /> EH 54.28 �C u -0-0 3 <br />