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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 /> PERMIT EXPIRES 1 YEAR FROM 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 compliarnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> 1�Joaquin County Public Health Services. <br /> r Job AddressCit <br /> Q ' <br /> � n y Lot Size/Acreage <br /> Owner's Name �>G���YJ U� Address►' `4?_- �9�yf� (�j ph e/�� <br /> Contract <br /> O AddressLicense No. Phon �' — <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL TEPLACEMENT n t of Service Wel <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR K OTHE Monitoring Well ❑ <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 <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> (I Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public F1 Other f-1 Delta Depth of Grout Seal _ Type of Grout / <br /> I I Irrigation Approx. Depth 1 I Eastern Surface Seal Installed by Y <br /> Repair Work Done LJ Type of Pump N.P. State Work Done <br /> Well Destruction O Well Diam Sealing Materiel i Depth <br /> Depth _ Filler Material L Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 AIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Pr rty Line <br /> L RING LINE Ll No. & Length of lines Total longih/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ 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 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 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 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 must call for all uired ins ctions. Complete drawing on reverse side. <br /> Signed X Title: _ �Ac � �/ tt Date: ^� <br /> p� R EPARTMENT USE ONLY p / <br /> Application Accepted by Vv Date S-) i l Area <br /> Pit or Grout Inspection by Date_ Final Inspection by Date y <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> Q 160 a ton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE <br /> CK INFO AMOUNT DUE A NT REMITTED CASH RECEIVED BY DATE (� PERMIT NO. <br /> H 13.24fReV.lin5r •�v 197919 <br /> .R <br /> H 1126 M R <br />