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APPLICATION FOR PERMITe <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE, , PHONE (209)468-34 qtr" <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PFAMIT EXPIRE 1 YEAR FROM DATE <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Lot Size/Acreage <br /> Owner's Name Address Phone <br /> aContractort )k4� _Addrss �Q CLJ]t!t_icense No, 1Phone X�6 ' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> I PUMP INSTALLATION ❑ r1 SYSTEM REPAIR ❑ a, OTHER ❑ Monitoring Well C7 <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 /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack-.-...,.. v E]-Tracy --Type of-C-asing Specifications <br /> I') Public I-) Other n Delta Depth of Grout Seal Type of Grout } <br /> i I irrigation —.Approx. Depth I I Eastern Surface Seal Installed,by t <br /> Repair Work Done 0 Type of Pump H.P. State Work Done .� <br /> Well Destruction © Well Diameter Sealing Material & Depth {� <br /> Depth Piller Material A Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I AIRJADOITION I I DESTRUCTION I I (No septic system permitted if public sewer is v <br /> I ' available within 200 feet.] ( h <br /> Installation will serve: Res' ante__.. V 1 } <br /> �Emmercial thea � <br /> Number of living units: Number of h qms� f <br /> Character of sail to a depth of 3 feet: CLA 0Water table depth s <br /> SEPTIC TANK ❑' T e/Mf <br /> Yp 9 ` Capacity "No"Compartr»enta - V <br /> EKG. TREATMENT PLT, 0 _ Method of Disposal \\ <br /> Distance to nearest: Well � Foundation - Property Line.� <br /> LEACHING LINE it iVij & Length of lines Topl length/size�� <br /> FILTER BED C] Distance to nearest: Well Foundation t-, Property Line <br /> f <br /> SEEPAGE PITS 14—'Mpth Size Nurriber <br /> SUMPS CI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 i <br /> Home owner or licensed agent's signature cenifies the following; "I certify that in the performance of the work for which this permit is issued, I shall n <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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The pplicant II of all r Or ins ns C plate wing o verse side Q <br /> Signe TiU Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Fit r Grout Inspection by_� ' Dat Final Inspection by Date �U <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public ealth <br /> -Services, -Environmental Realth'Permit/Services �... _.. ..w ,.� <br /> r 1601 E. Lzelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO jj,�/1/ L /� C/A�SH DATE p PERM17'NO. <br /> + 1:H 13-24 tREV.iinsl f l �� Lfl 1'�� A13 �s0'� fo v�'�r-r ! <br /> EH 4426 f <br />