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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 BOR 2009, STOCKTON, CA 95201. <br /> i <br /> 1 PERMIT EXPIRES I YEAR FROM DAZE 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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Servic <br /> Job Address - City e Lot Size/Acreage _ <br /> Owner Name,f�� Address Phone <br /> tZS��� ' �dLS10S <br /> Contract Address .:h, License No Phone <br /> a <br /> TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.CI DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> n Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'I Public ill Other Fl Delta Depth of Grout Seal Type of Grout <br /> 11 Irrigation _.Approx. Depth I I Eastern Surface Seal 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 /> Cr <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I kREPAIR`/ADDITiONK DESTRUCTION I 1 iNo septic system permitted if public sewer is <br /> ! available within 200 feet.) <br /> Installation will serve: Residence Commercial>< OtherIn <br /> Number of living units: Number of drooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. '61,�Typel Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 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 >(_Depth Size, _ Dumber <br /> SUMPS Ll Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with $an Joaquin county ordinances, state laws, and <br /> rules and regulations of the San,Joaquin. County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance.of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant us It for al re 'red ' spections. Complete drawing on reverses dV. <br /> i <br /> Signed Title: / Date: <br /> FOR DEP RTIVI NT USE ONLY <br /> Appllication Accepted by Da4e �' A're-a (/ <br /> t,Gr Grout Inspection by _ Date final Inspection byata_ ( <br /> Additional Comments: <br /> Applicant — Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> INFO 1 AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> i EH 13.24(REV.!i H$! !Et_7Q �lzr = <br /> EM 1.4.26 / -I <br />