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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONEi (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> ' R$ 'AR FRQR D <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County ror a permit to construct and/or install the work herein described. This <br /> application In made in compliance with Sea Joaquin County Ordlnance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address q O Cit Oc Lot Size/Acreage <br /> Owner's Name Agd2/5 '60 Address <br /> Phone <br /> Contractor A L I,/?R191s;N) Address Rd t ST • asp 0)"- 4-- License No, f 9760t; Phone a 71-a A—) r� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT G DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl' Monitoring well ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation pia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack Cl Tracy Type of Casing Specifications <br /> Public 1-1 Other n Delta Depth of Grout Seal Type of Grout^'^cA-1,1,.T <br /> f I IrngaWn —Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Nell Destruction ❑ Well Diameter Seng llrterial i Depth <br /> ,3,61c J,4a,,P­'N6- ! / Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIAODITION I I DESTRUCTION I I fNo septic system <br /> permitted if ptibLc sewer is <br /> x. 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 0 Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size ! <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work wilt be done in accoraan_ce 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: "1 certify that in the performance of the work for which this permit is issued, l shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature 4 <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 Iowa of California." <br /> Theapplicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: 'I.?Ary <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> 4 i <br /> Additional Comments: <br /> 1 <br /> Applicant Return all copies to.- Ban Joaquin County Public Health <br /> Services, Environtsent:al Health Permit/Services <br /> 1601 E. Saselton Ave.. P 0 Box 2009. Stockton. CA 95201 <br /> FEE 1 AMOUNT DUE AMOUNT REMITTED "�OKs RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> • Ekt7ZIfI1EVIf R <br /> . "MUD <br /> E� �.m S� <br />