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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 W <br /> P 0 BOR 2009, STOCKTON, CA 95201 E <br /> PF"IT MIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) U <br /> Application is hereby made.to Sen 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 Services, �r <br /> Job Address I, City sfo Lot Size/Acreage T(O0 <br /> Owner's Name 4+ Y F' -ZI Address r i3 Phone <br /> Contractor �� <br /> Rddress License No. L47_1!2Phone <br /> TYPE OF WELL/PUMP: Nt9l WELL ❑ WELL REPLACEMENT n 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 PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA I CONSTRUCTION SPECIFICATIONS <br /> CI Industrial ❑ Open Bottom © Manteca i.,Dia..ofrWell Excavation Dia. of Well Casing <br /> El Domestic/Private L1Gravel Pack 0 Tracy t Type of Casing Specifications (w <br /> l'I Public I-1 Other n Delta ,Dppth of*Grout Seal Type of Grout <br /> I I Irdoation —.Approx. Depth t I Eastern Suriace 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 i (� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITION I I DESTRUCTION ^ (No septic system permitted it public sewer is <br /> available within 200 feet.i I <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: 1 Water table depth <br /> SEPTIC TANK. ❑""Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE L1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number t <br /> a <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> hereby certify that 1 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 f <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 taws 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 m II for all required i diens. Complete drawing on reverse side. <br /> Signed X Title: ® /�1I'�tLr Date: 4 <br /> RTMENT USE ONLY <br /> i Application Accepted by @CI&& '"` Date ' ' _.— Area <br /> 1 Pit or Grout Inspection by J Data .Final Inspection by Date <br /> Additional Comments: f b 1 Gv <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health-Permit/Services <br /> 1601 S, "Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA5H RECEIVED BY DATE PERMIVNO. <br /> INFO <br /> a EH 13.24(REV,r/N 51 c.t,� l [l ��� l l�� P 33 7 <br /> EH 14.26 [[[ <br />