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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � Y <br /> ENVIRONMENTAL HEALTH DIVISIONT y <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 " / <br /> P O BOX 2009, STOCKTON, CA 95201 [ � <br /> EXP RES 1 YEAR FROM DA E W <br /> (Complete in Triplicate) <br /> Application is hereby rade 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 /> 31:7 Job Address (�1� _ (!� City i� Lot Site/Acreage <br /> ' Owner's Name uJ ry_� [/��,�lJ � `., - teas Phone "76Contractor Address - NTYPE OF WELL/PUMP; NEW WELL WELL RE LACEMENT C� DESTRUCTION 0 Out of S <br /> PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER 0 Monitoring Well L7 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. r�n PROP. LINE <br /> FOUNDATION AGRICULTURE WELL 4 OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFiCATIO v <br /> n Industriall! <br /> ❑ Open Bottom 0 Manteca Dia. of Well Excavation_ 4- Dia. of Well Casing <br /> 11 Domestic/Private Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public 1-1 Other n Delta Depth of Grout Seal _sEl7 Type of Grou <br /> i hri0ation / ,Approx. Depth }Eastern Surface Seal Installed by <br /> , I0 Type of Pump H.P. State Work Done _ <br /> ell DZ0 Well Diameter Sealing Material & Depth <br /> 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 /> Installation 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. 0 Type/Mfg Capacity_ <br /> PKG. TREATMENT PLT. C7 Na. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size j <br /> FILTER BED 0 Distance to nearest; Well Foundation Property Line <br /> SEEPAGE PITS 1 ) Depth Size <br /> Number <br /> SUMPS LI Distance to nearest: Wali Foundation <br /> DISPOSAL PONDS El - —� 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, I shall not <br /> employ any person in such manner as to become subject to workman's comps nsation laws of California."Contractor's hiring or sub-contracting signature <br /> certi onrfaws of following:i a ,I certify that in the performance of the work for which this-Permit mit is issued, I shall employ persons subject to workman's compansa- <br /> The applicn t to fl re red - —­14� <br /> pections. Complete drawing on parse aid �t- <br /> Signed X Title: <br /> -- 1� Data: <br /> R DEPARTMENT USE ONLY 4 <br /> Application Accepted by Dats �- I'� <br /> /� <br /> Area <br /> rout <br /> Pit or nspection by Dat '471' Fin Inspection by�K r� ^ <br /> Data <br /> 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 19-24IREV.riw6) Q� <br /> EH 14-28 } �� G <br />