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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 O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT FIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to Safi 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. - ,,ff <br /> `4 <br /> Job Address 1�. ��n�` Cit Lot Size/Acreage 'c N 2-0 <br /> Owner's Name 0,'EkCE1Q ��— ► Address 1w �QaPhone <br /> Contractor 1 S Address .y '"' U - License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTV DESTRUCTIONOut of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ !HER ❑ Monitoring Well o <br /> DISTANCE TO NEAREST: SEPTIC TANK ^ SEWER LINES DISPOSAL FL PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL f PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />' El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav ' n Dia. of Well Casing U / <br /> XDomestic/Private )9 Gravel Pack XTracy Type of Casing Specifications O <br /> p i"1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by <br /> i Repair Work Done ,U/ Type of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material & Depth <br /> „ Depth Filler Material & Depth <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION l I INo septic system permitted if public sewer is <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. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> t <br /> SEEPAGE PITS 11 Depth G Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 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." t <br /> TheappI' must tail for all required inspections. Complete drawing o reverse side. <br /> Signed Title: _ Dater_� <br /> FOR EPARTMENT USE ONLY <br /> Applicatlon Accepted by Date - Area <br /> AelPit or Grout Inspection by Date Final Inspection by Dated aI <br /> t Additional Comments: <br /> Applicant – Return all copies toi 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 CASH RECEIVED BY DATE PERMIT'NO. <br /> . EN 13-2I(REV.I R5) Y ! D .L}.J '06 lc-:� <br /> EH 1I-X NNN <br />