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APPLICATIGN FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH .SERVICES <br /> _ 1 ENVIRONMENTAL .H_9ALTH DIVISION <br /> _ 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> �� P 0 BOX 2009, STOCKTON, CA 95201 <br /> Il/ HERMIT EXPIRES 1 YEAR FROM DATE I8$UED <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 S1 A <br /> Joaquin County !Public Health <br /> ServiCea. <br /> ,( <br /> Job Address �6! ���+J r� /� City Lot Size/Acreage <br /> Irv4to <br /> "WW � <br /> Owner's Name "\ � t� Address Phone <br /> Contractor ��2LS Address7 <br /> License No: y_M-*YS_Phone,� <br /> TYPE OF WELL/PUMP: NEW.WELL D WELL RE LACEME{Mj Off <br /> DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION D SYSTEM REPAJA ❑ OTHER+t Monitoring Well ❑ S1 <br /> 4 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE T� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (1 Industrials III Open Bottom E3 Manteca Dia. of Well Exct+'veiion t Dia. of WAII Casing <br /> C l Dofnestic/PrivateElGravel Pack LlTracy Type of Casing dk Specifications <br /> i' <br /> I'I Public' (.1 Other FI Delta Depth of Grout S691 Type of Grout <br /> .I <br /> I lrripation Approx. Depth I I Eastern Surface Seal Instislled by <br /> �04� t Work Done Ll Type of Pum iWP H.P. + State Work Done _ <br /> �It struction b Well Diameter Sealing Material i Depth <br /> iy Depth Filler Material Z Depth <br /> + <br /> TV F SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I`INo septic system permitted it public sewer is <br /> v Available within 200 feet.) <br /> Int {on will serve: Ffesidet ce X Commercial Other <br /> Num*HvinA uri`ts: __ Number of bedroo <br /> Charsct;0 at:�to a depth of 3 feet: �� <br /> ??�� Water table depth .� <br /> SEPTIC TAAK,f.', ❑. Type/Mfg_.+ Capacity OO< <br /> r_ P Y No. Compartment <br /> = PKG. TREATfiI ��L�,�1 Method of Disposal L <br /> ?�. <br /> Distance td nearest: Well c Fbundation O�;Property Line <br /> `Il_ LEACHING LINE �t ;No. 6 Length of lines / / T4. <br /> LEACHING <br /> FILTER BED ❑ Distance to nearest: Well .2 Foundation _1, _ Property Line Ali <br /> SEEPAGE <br /> SEEPAGE PITS 11 Depth Size ,Number C <br /> SUMPS LI Distance to nearest: Well �ao Foundation 'dd/ 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 mall for iredtspections. Complete drawing on reverse side. <br /> u <br /> Signed X Title: aezzwl� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �� G�-� Date �` - Area /I <br /> yl i or Grout Inspection by `bate �� Final Inspection by-Z(f K e . / Date <br /> Additional Comments: }. <br /> t <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 95201FEE <br /> r <br /> INFO AMOUNT DUE AMOUNT REMIT-TED CK i*CASH RECEIVED BY DATE PERMIT NO. . <br /> -u i4NtREV +ih5i <br />