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r APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ' 1601 E, HAZELTON AV . , PHONE (209)468-3420 NIACHADOIF INC. <br /> P O BO% 2009, STOCKTON, CA 95201 247 N.JacktOne Road <br /> cJ I RE 1 DATE FROM ED <br /> Stockton, (x`111100 is 96216 <br /> 11' <br /> ii (COmplete in Triplicate) <br /> fApplicatianis hereby made to San Joaquin County for a <br /> in <br /> application is made in compliance with San Joaquin County work yOrdinance No. 549mit to construct 8and o1862sand lthe eRules and eRegulationsdof Sans <br /> 4 Joaquin County Public Health Services. <br /> i Job Address d-00 0 E-5-2� <br /> City Ir <br /> o a/Acreage <br /> Owner's Name Address � <br /> f Phone <br /> Contractor Address '�' <br /> TYPE OF WELL/PUMP: ��_ License No, �Qc �Phone <br /> € NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR <br /> DISTANCE TO NEAREST; SEPTIC TANK i OTHER ❑ Monitoring Well i] <br /> - � SEWER LINES DISPOSAL FLD, <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> OTHER WELL ' PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Man~ taco —Trac <br /> --f�rpomestic/Private 0 Gravel Pack L7 ` <br /> Dia. of Well Excavation Dia. of Well Casing <br /> I'1 Public f l Other y Type of Casing Specifications <br /> ,.+ . a n Delta 'N Depth of Grout Seal <br /> + I Irrigation ---;Approx. Depth - I I Eastern Type of Grout <br /> i Repair Work Done � <br /> TYABof Pump' ' Surface Seal Installed by <br /> H.P. � .- <br /> Weil Destruction O Well Diameter ^ Sealing Material & Depth State Work Done ` II <br /> Depth Filler Material & Depth N <br /> TYPE OF SE TIC WORK; NEW INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION I I INo se ric system! P Y permitted if public sewer is <br /> Installation will serve: Residegce` CommercialOther available within 200 feet.l <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity. No. Compartments -� <br /> Distance to nearest: y Well A r Method of Disposal <br /> B <br /> 4 Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest`: Well Total length/size <br /> Foundation Property Line ^ <br /> SEEPAGE PITS € I depth' <br /> SSize Number <br /> SUMPS <br /> Ll Distance'io nearest- '# : Well <br /> DISPOSAL PONDS :P t: Foundation Property Line <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, f 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 ermit is issued, i shall C to <br /> tion laws of California." p employ persona subject to workman's compensa- <br /> The applicant all for all require spec ns, Complete drawing on rave ide. <br /> -------------- <br /> Signed <br /> OV <br /> Title: <br /> Date: <br /> O ARTMENT USE ONLY � <br /> Application Accepted by ` ,��G <br /> l <br /> Pit or Grout Inspection by Date Arear+ <br /> Date-----•�_ Final Inspection by T <br /> Additional Comments: Date <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services �I <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton CA <br /> EEE 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMI7'N0, <br />+ EN 13Q4{REV.€ins€ <br /> EH 74•29 <br />