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I APPLICATION FOR PERMIT PAY { <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ��� ��� <br /> ENVIRONMENTAL HEALTH DIVISION NAR 2 0 <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 SANjo ��g, <br /> P 0 BOR 2009, STOCKTON, CA 95201 E,1V BLIC H �IN Co ujvrY <br /> PERMIX EXPIRES 1 YEAR FROX DA ��MNrq[MfA rH prV <br /> + � (Complete in Triplicate) &)�� _ SIQN <br /> ,'+Tr <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> c application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. [ <br /> Job Addres �r T City�Ld ---- Lot Size/Acreage <br /> Owner's Name Address Onto Ph9�6 <br /> ., f <br /> 15 � 61PiS /l rL5 +moi <br /> Contractor C Address £• 'RE.J>�. License No510? Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Out of Service Well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> { DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES '?:5-6 DISPOSAL FLD�>50 PROP. LINE <br /> i FOUNDATION ?SZJ AGRICULTURE WELL �dOTHER WELL OPI PITS/SUMPS>S0 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LL W <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Ckng f/ i <br /> D Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing Specifications O <br /> V1 Public 1.1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> t I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> + Repair Work Done 0 Type of Pump H.P. State YVork Done <br /> .e�'t & f <br /> Well Destruction � Well Diameter Sealing Material Depth <br /> -----f /' <br /> Depth r r Filler Material & Depth il�JCrlli <br /> N TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> w . <br /> `i 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. ❑ Type/Mfg Capacity---- No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> fI <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED C1 Distance to nearest: Well Foundation Property Line <br /> f1 <br /> ' SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation 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 applic t call for el iced inspections. plate drawing on reverse si e. <br /> Signed Title: Date: <br /> /�N P FOR DEPARTMEN USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Date Ir- 411) Final Inspection by Date <br /> a Additional Comments: <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 95201 <br /> INFO FEE A/Myp//�V±±±NT DUE AMOUNT REMITTED CASH LVED BY DATE df PERMIVNI0 <br /> + EH 13-2�(R EV.f i n 5+ 7�/�/� /3 y L � t. y f�� <br /> EH 14.26 V vv V L <br />