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6 � 0APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address SJR' r0. kKq eo,_ City Lot Size/Acreage /3 Qcr-ea <br /> -3:o <br /> Owner's Name Address -St""��` Phone <br /> �Q�_ � _ �{e5 a. S5'f�tFf Slv� <br /> Lra t`o�- `^ G Address. _ License o. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 0 DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U <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 Or <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav tion Dia. of Well Casing b <br /> i.I Domestic/Private ❑ Gravel Pack Tracy Type of Casing da S4�- Specifications <br /> Il Public Other f'1 Delta Depth of Grout Seal Tv a of Grout �` <br /> I I Irrigation � Approx. Depth I 1 Eastern Surface Seal installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ IILtNC <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADOITION I I DESTRUCTION I I (No septic system permitted it public sewer is <br /> • lnstallatioa will serve: Residence-.• Commercial — Other available within 200 feet.) <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 Property AkYAWNT <br /> REeEIVED <br /> LEACHING LINE ❑ No. & Length of lines Total length/siz <br /> FILTER BED ❑ Distance to nearest: Well Foundation Propert <br /> SEEPAGE PITS 11 Depth Size Num (PUBLIC HEALTHSFRVICFS <br /> SUMPS LI Distance to nearest: Welt Foundation "$r MLUTAL HEALTH DIVISION <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: 1 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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m st call for all required inspections. Complete drawing on reverse side. _ •Q �j <br /> Title: L St Date: <br /> Signed -- - <br /> f- FOR DEPARTMENT USE ONLY <br /> i ` —- -sem <br /> Application Accepted by Date Area_ 3 �• "' <br /> V <br /> Pit or Grout Inspection by Date Final Inspection by DW <br /> Additional Comments: r { )I1 <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> f <br /> Services, Environmental Health Permit/Servicee <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT AUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> . EH 13-14(REV.riA� � ✓ <br /> EH.t-gyp 1f <br />