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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERI[IT EXPIRES 1 YEAR FRAM 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 /> 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 / N L Cit ize/Acreage <br /> Owner's Name C.- Address 3 Y 72 7 ` �����Phone <br /> iL�_l r 27, ©U9 <br /> ContractorAddress 1 / cense No.1!/6✓z? Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ I : WELL REPLACEMENT'c) DESTRUCTION ❑ Cut of Service Well ❑ <br /> PUMP INSTALLATION-t ` r s,,.i SYSTEM REPAIR Ek--- OTHER. ❑ Monitoring Well U <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES` ! DISPOSAL FLD, ;PROP: LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL IPIT,S%SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> 1 <br /> f-1 Industrial ❑ Open Bottom C3Manteca Dia. of Well Excavation D a. of"hWeII Casing <br /> 1+1'6omestic/Private ❑ Gravel Pack D Tracy Type of Casing 1 Specifications <br /> � 3 <br /> I'I Public i.l Other h1 Delta Depth of Grout Seal Type of Grout <br /> r M <br /> I I Irrigation �f —Approx. Depth I I Easter ,�yrfaca Seal Installed by ,At,,�. <br /> Repair Work Done L/ Type of Pump 0e�.P. /Z State Work Done l> 1h 4 <br /> Weil Destruction ❑ Well Diameter--_i 1A t (A tNSef ling Material & Depth � <br /> Depth ---Filler Material & Depth � <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system;permittediit public sewer is <br /> available within 200 feel,► <br /> Installation will serve: Residence_ Commercial_ Other 11 I ; <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: ! Water table 6epthi1 <br /> s <br /> SEPTIC TANK. ❑ Type/Mfg Capacity - __,_,-,No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of pisposal <br /> Distance to nearest: Well Foundationt, � Property.Line -+� <br /> LEACHING LINE Cl No. & Length of lines 1 Total length/size <br /> l <br /> FILTER BED ❑ Distance to nearest: Well Foundation'.' � P.rpperty Lint ; <br /> SEEPAGE PITS 11 Depth Size K- :--Number­ <br /> SUMPS El Distance to nearest: Well Foundation ' l Property Line <br /> DISPOSAL PONDS ❑ -A <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 4� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the p0`rformance of the work for which this permit is issued, I shall not <br /> employ any person in suc nner as to become subject to workman's compensation,•Iaws of California." Contractor's hfiring or sub-contracting signature r^ <br /> certifies the fodowi t cert that in the performance a work for which this penriit is issued, I shall employ persons subject toy workman's compensa- <br /> non laws of Cal' mia." I ; <br /> The applican s or requir i plate on r side I•, <br /> Signed -7Title: Dale: <br /> Or, FORa.L7,DEPARTMENT USE ONEY IApplication Accepted by __ .tL - _ C_ti &.a Date ' Areal <br /> Pit or Grout Inspection by C Date Final inspection by s Date <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 /> IFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24 IFIEV,1/n 51 L�..�` CVD r�v C <br /> EH'v4 Ze Vim- 1 V (/� <br />