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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 /> RES ;AR-FROM DATE- ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or instal]. the vork herein described. This <br /> application is made is compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations or San F <br /> Joaquin County Public Health Services. <br /> JobAddress LL a? B Cit ociC Lot Size/Acreage <br /> Owner's Name U Address Phone <br /> i <br /> Contractor w �c c <-- .Address e ,zd L.4 License No. Phone / GG/ <br /> TYPE OF WELL/PUMP: NEW WELL 3' WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationpia. of Well Casing `1 <br /> C1 Domestic/Private CI Gravel Pack 13 Tracy Type of Casings r� Specifications r',, <br /> i'1 Public CZ Other n Delta Depth of Grout Seal Type of Grou e <br /> gn <br /> 11 Irrigation —Approx. Depth 11 Eastern Surface Seat Installed by <br /> Repair Work Done 0 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 i DESTRUCTION I I INo septic system permitted it pllbl+c sewer is <br /> *. available within 200 feet.) <br /> Installation will sena: Residence_ Commercial— Other 1. <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depot of 3 last: 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 ❑ No. & Length of lines Total length/size <br /> L FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Sire Number ' <br /> SUMPS LI Distance to neatest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> F^' I hereoy certify that I have prepared this application and that the work -il be done in accordance with San Joaquin county ordinances. state laws. and <br /> L 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 sutrcontracting signature <br /> certilies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ persons sub)ect to workman's compansa- <br /> tion laws of California." <br /> Theappiic�a-nntt/Jmust call for all r uired inspections. Complete drawing on reverse side. <br /> Signed X L`L `_� C Title: Date: <br /> FOR DEPARTMENT4SE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Final Inspection by 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., F 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO SASH <br /> • EM 13dk IREV.t/e 51 r <br /> EK:426 <br />