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MI <br /> f 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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES-1 YEAR F9QM 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 /> f 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 /> k Job Address ' Clty Lot Size/Acreage <br />[ Owner's Name -S+� f -. Address ' + Phone <br /> 1 <br /> Contractor v/ "-+ Address License No, C rPhone <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well Cl <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 /> C-) Industrial I . , © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> .El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public, t ` CD OfherCl Delta Depth of Grout Seal Type of Grout <br /> ~i I Irrigation {_ { . . Approx. Depth I I_Eastern Surface Seal Installed by <br /> �• �•^-.at - , + � ,fit.. <br /> Repair Work D e L] Type of Pump - A WID. State Work Done <br /> Well Destruction ❑ Well Diameter"' '`• +'' Sealing Material A Depth <br /> Depth f Filler Material & Depth <br /> TYPE OF SEPTIC WORK NEW INSTALLATION. REPAIR/ADDITION l I DESTRUCTION I I INo septic-system permitted if public sewer is \I <br /> available within 200 feet.l <br /> Installation will serve: Residence Commercial_- Other <br /> f <br /> Number of living units:/!2r_,' Nu:mbit`sr of.bedrooms .. <br /> Character of soil too depth of 3 feet:�, Water table depth <br /> SEPTIC TANK �f ❑ Type/Mfg� 'No-Compartment, - <br /> k PKG. TREATMENT PLT, ❑ r ; r Method of Disposal <br /> E Distance to nearest: Well r _ Foundation.Sr Properly Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: ell Foundation r Property Line I 0 <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS f LI/1'Distance-to nearest:.. Well Foundation Property Line <br /> DISPOSAL PONDS C)f�, > <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 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 applica �fo �l r�ui�red ins ctions. Complete drawing on reverse side.Signed X `lYn� Title:__ (� Date: <br /> FOR DEPARTMENT USE ONLY �/O <br /> Application Accepted by Date l Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> k7 47o 4­4 �- � <br /> Additional Comments: <br /> Applicant - Return all copies to:' San <br /> pp op Joaquin County Public Health <br /> Services, Enviromaental"Health Permit/Services <br /> T 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE JtMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMI7'NO. <br /> INFO <br />{ EH 13-24 IREV,I/a 5) IZ& <br /> EH A-2E �/ G' <br />