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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 /> r. - PEMIT 'EXPIRES 1 YEAR`FROM DATE ISSUED <br /> , 3@ c ;�J_ A-vi ��"?;� (Complete- in Triplicate) ,'J <br /> Application Is hereby made.to San Joaquin County for a permit io`construct and/or install the work herein described. This <br /> application is made in ccupliance with San Joaquin County Ordinance No. 549,and.1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> CAST" U►S D <br /> Job Address oP DP . /1V1)2r1 i}r- PG-L7iG �7`kyy <br /> City_ �LJot Size/Acreage <br /> Owner's Name G LLA EM- 1 f CU& Address V� I C� ���L��L `la ti Phone <br /> Contractor MAn L�`e d Address Sd E- F Q_t mq7,, /U License No..512 tJ f i Phone d2J <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT F- DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP.INSTALLATION"? SYSTEM REPAIR ❑ OTHER O Monitoring Hell`-.0 <br /> DISTANCE TO NEAREST: SEPTIC TANK •SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION � l C <br /> AGRICULTURE WELL OTHER,WELL PITS/SUMPS <br /> C <br /> INTENDED USE TYPE OF WELL /PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E Industrial ❑ Open Bottom 1 C1 Manteca Dia, of Well Excavation -Dia- of Well Casing ' <br /> F] Domestic/Private /Gravel Pack/ ❑ Tracy Type of Casing Specifications / <br /> I"1 Public Cl Other 11 Delta Depth of Grout Seal Type of Grout <br /> -- <br /> Irrigation /Approxi Depth--I-i-E"16F `Surface"Sea l-installed be i <br /> y-- — <br /> Repair Work Done U Typeof Pump T[iR�//l�� H p ) //./0 State Work Done—tlid S <br /> Well Destruction O• Well Diameter Sealing-Material`& Depth - 17 U,OA 0 /IJQU� <br /> t� Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> `r 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. O Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ClDistance to nearest: Well Foundation ti L Property line <br /> SEEPAGE-PITS— -- I-1-Depth — - -Size'-- = - .'— Nurnber' - � <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <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." 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 applican call for all required inactions Complete drawing o ver side. D nn //�� / J <br /> Signed C Title: C'"�IX�CI Date: U <br /> —MPIZPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by�l"` <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environtaental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009. Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> DINnF�O /� CASH RECEIVED BY PATE PERMIT'NO. <br /> • FH u.ie IREV.ring 1 f Y Ll <,-, oo 1 \1 <br />