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APPLICATION, FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-5420 <br /> P 0 BOR 2009, STOCKTON, CA 95201 <br /> I EXP RES 1 YEAR FROM DAT <br /> (Complete in Triplicate) <br /> Application is hereby made to SanFJoaquin County for a permit to construct and/or Ins62 tal the the <br /> Rules work <br /> hereand in <br /> described. <br /> Sans � <br /> application is made in compliance <br /> and <br /> `' <br /> with San <br /> fJ (Joaquin <br /> /I!County Ordinance N 549 <br /> Joaquin County Public Health Services, i <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> 4 <br /> Owner's Name dress <br /> Contractor Address <br /> 'cense N Phone <br /> NEW WELL ❑ <br /> �,mp, ACEMENT DESTRUCTION ❑ Dut of Service Well ❑ <br /> TYPE OF WELLIPUMP: OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION —.AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom`- . ❑—Manteca Dia. of Well Excavation Specifications <br />[ Cl Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing <br /> 1 n Delta Depth of Grout Seal Type of Grout <br /> I'l Public 13 Other <br /> I I Irrigation ___.Approx, S <br /> Depth I I Eastern Surface Seal Installed try <br /> of Pump M.P. State Work Done ,T <br /> Repair Work Done C7 Type Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter <br /> t Filler Material pth <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I I (Niro sepelwit hin 20c stem 0 feet.) <br /> if public sewer is �_ <br /> f <br /> Installation will serve: Residence 4 Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> No. Compartments' <br /> r -�* - +-"»• -- Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 4 <br /> Total length/size v <br /> li Foundation -- Property Line <br /> FILTER BED CI DistanceIto nearest: Well yD� <br /> Number - r--� <br /> SEEPAGE PIT 1 1 Depth Size <br /> PS <br /> Ll Distance to nearest: Well - 'Foundation_164 . 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 /> k rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "i certity that in the performance of the work for which this permit is issued, I shall nQ,-Z <br /> ibecome subject to workman's compensation laws of California," Contractors hiring or sub-contracting signs <br /> employ any person n such manner as to r <br /> certifies the following: "1 certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compens <br /> tion Jaws of California." <br /> The applicant must II for all re ed inspections. C piste drawing on se side. <br /> Signed X <br /> Title: r Dale: <br /> FOR DEPARTMENT USE ONLY <br /> Date 7 <br /> A fication Accepted by <br /> l <br /> t/ �_ Date 4 <br /> J Pito Grout fnspeetio Date .Final Inspection by <br /> dditional Comments: r <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, ]environmental Health Permit/Services <br /> 1 1601 E. Hazelton Ave., F 0 Box 2009, Stockton, CA 95201 <br /> F CK <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH <br /> RECEIVED BY DATE PERMIT NO. <br /> r GG <br /> . Em 19-24 1SEV.I/As) INFO /N.0 �.� "�' (o" 7 0 CIO 7,20 <br /> EH U-2E <br />