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APPLICATION POR PERMIT <br /> SAN QUIN COUNTY PUBLIC HEALTH SEYICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> i 1661 P: HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOR 2009; STOCKTON, CA 95201 <br /> XP RES YEAR FR M PAMAOM <br /> (Complete in Triplicate) <br /> Application is hereby mnde to San Joaquin County for aermit to !1 <br /> applic"'on is made in compliance with Sart Joaquin County OrdlnancenHo. 549 andtruct ano18628tall and theework a <br /> Rules ndeRegulations of Sans <br /> Joaquin County Public Health Services. <br /> Job Address 3 ai ma., r 0.5" Ed City <br /> � .�}l Lot Size/Acreage <br /> Owner's Name B,�-J C i Address _r� ?�,i _�. In 1 a r; nne., HCl S, �c *hone <br /> Conhactor Address �e c <br /> License No•.5�—Phone - 7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ E DESTRUCTION E-) Out of Service Well ❑ <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0- <br /> DISTANCE TO NEAREST: SEPTIC TANK -n4— SEWER LINES' )0h, ` DISPOSAL FLD.h1a. _ PROP. LINE -Z3C6 <br /> FOUNDATION -ILL— AGRICULTURE WELL OTHER WELL :r PITS/SUMPS 11114 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Cl Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation `1 Dia. of Well Casing rr <br /> Domestic/Private .)RGravel Pack ❑ Tracy Type of Casing PVC, g <br /> f'I Public ` f Specifications <br /> f 1 Other A Deha Depth of Grout Sea! Type of Grout m n C <br /> I l lni anon r <br /> 0 �.Apprarl. Depth ! 1 Eastern Surface Seal Installed by�i• t b'Qn <br /> Repair Work Done 0 Type of Pump <br /> H,P, Stale Work D ne I <br /> Well Destruction ❑ Well Diameter Sealing Material a Depth ! <br /> Depth Filler Materiel A Depth _a 4` Seto _ <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 /> Installation will terve: Residence— Commercial— Other available within 200 leet.) <br /> Number of living units: Number of bedrooms <br /> Character of coil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mig Ca Acit # <br /> p Y �' No. Compartments <br /> PKG. TREATMENT PLT. CI Method of Disposal 1 <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. A Length of linea Total lfength/size C <br /> FILTER BED © Distance to nearest: Well Foundation E Property Line 1 <br /> SEEPAGE PITS 11 Depth Sire Number <br /> SUMPS LI Distance to nearest: Well Foundation � Pro <br /> DISPOSAL PONDS ❑ party Line_ <br /> 'E 4 <br /> I hereby certify that 1 hevR prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I <br /> rules and reguistiont of the San Joaquin County <br /> Home owner or licansdd Agent"s tlpnature certifies the following: "I certify that In the performancelsof the work for which this permit is issued, I shall not <br /> employ any porion in ouch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatu <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's campsnaa <br /> re <br /> tion law*of California." <br /> The applicant must cell for all required In actions. Complete drawing on reverse tide. <br /> Signed?C��,t �� Z <br /> s- Title: Date: <br /> FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by <br /> Date Area �J <br /> Pit or Grout Irlspeclion by Dat ; + <br /> ---�_.. Final Inspection by ' Date <br /> Additional Comments: G <br /> Applicant - Return e11 copies tot San Joaquin County Public Health + <br /> Services, Environmental Health Permit/Service's <br /> 1601 E, Hazelton Ave., P 0 Box 2009, Stockton," CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTE!] <br /> INFO CASH RECEIVED BY, DATE PEAmMNO. <br /> H 12,21(REV.1/r Sr - <br /> IH;�•?e <br /> Ij <br />