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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 /> REMIT EXPIRES-1 YEAR FROM DATE I§4SUED <br /> (Complete in Triplicate) <br /> Application is hereby Stade 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 1862 and the Rules and Regulations of San <br /> Joaquin County.Public Real t Services. <br /> Jab Address ,' Z'A City Lot Size/Acreage <br /> Owner's Name K� Address Phone <br /> Address& Z67 /&t7-e License No. 7Az74 Phone �f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O 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 i <br /> n Industrial ❑ Open Bottom L7 Manteca Dia. of Well Excavation Dia. of Well Casing J <br /> [I Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public 1-1 Other n Delta Depth of Grout Seal Type of Grout ° <br /> I I Irrigation —.Approx. Depth € I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material & Depth <br /> Depth ler Material 5 Depth ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I k AEPAIR!#DDITION DESTRUCTION I 1 INo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve". Residence Commercial cher } <br /> Number of living units: Number of be s <br /> Character of soil to a depth of 3 feet: Water table depth o <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ° <br /> PKG. TREATMENT'PLT• ❑ Methad of Disposal / <br /> Distance to nearest: Well Foundation Property Line; <br /> LEACHING LINE '" ❑ No. & Length of lines Total length/size <br /> FILTER BED -� ❑.LDistance to nearest: Well Foundation Property Line:- <br /> SEE-PAGE <br /> ine:SEI PAGE PITS � Depth Size Number <br /> SUMPS LI- Distance to-nearest' Well�Q, _ Foundation-/40 c Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 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 followings "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 ust call r tl quired inspections. Complete drawing on reverse e. <br /> k / <br /> Signed X Title: -- Date: ` <br /> 0 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �r Are J 2_ <br /> Al ell, <br /> 0it or Grout Inspection by _ Date Final Inspection by Datay��` <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED CK I RECEIVED BY DATEPERMIT'NO. <br /> INFO CASH <br /> EH 13-24(HEV.i�n 5) 5 IN <br /> i EH 14.26 t 0-0 J' <br />