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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i ENVIRONMENTAL HEALTH DIVISION <br /> 1£01 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EBPIRES 1 YEAR FROM DATE- SSS <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 .�d � S• �tr1KY B,..vp City Lot Size/Acreage <br /> Owner's Name dtj �.� -- Address T* --- Phone <br /> Contractor�60"AgE9 Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ <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 /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public 1-1 Other 171 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 0 T p <br /> p Type of Pum H,P. State Work Done._ <br /> Well Destruction ❑ Well Diameter Sealing Material 8 Depth d <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION lNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Numbier of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg nts= Capacity No, Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal (1 <br /> Distance to nearest: II <br /> We Foundation property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED Cl Distance tri nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 8 Depth Size Number <br /> SUMPS _ Ll Distance to nearest: Well Foundation Property Line <br /> r � DISPOSAL PONDS �❑- .. �,3.. ..� . <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." I1 <br /> The applicant ust calf for all required inspections. Complete drawing on reverse side. <br /> Signed Title: 4ag=&i= Date: <br /> FOR AR USE ONLY <br /> Application Accepted by Date Area }/a <br /> Pit or Grout Inspection by Date Final Inspection by Date 2 4 <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services pt.� <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201FEE <br /> (�� <br /> INFO AMOUNT DUE t AMOUNT REMITTyE�D RECEIVED BY DATE PERMIT'N0. <br /> • EH13'244REV.1/NS) ,00 �{� afLOrj �o-�-Ci1?0— ] <br /> EH 64.28 /.S <br />