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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SE"ICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 PHONE (209)468 <br /> E. BOXL2009t STOCKTON, CA 95201-3420 <br /> P 'IT FxPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> i <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of inn <br /> Joaquin County Public Health services. <br /> erG U TL„ A✓� City�' � Lot Size/Acreage <br /> �� J <br /> Job Address <br /> iw s 3 <br /> Owner's Name � , Phone <br /> a P at Address i�� <br /> �� y/G <br /> 3GGr3 aflt 6 t Ci/�c�'”- <br /> Contractor <br /> �� �R�t c r/1/G CO. Address -��� 6 • �A^la/yo CoQOoVALicense No. S�`�•28 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ffi* WELL REPLACEMENT LJDESTRUCTION O Out of Service well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR O <br /> OTHER ❑ Monitoring Well Er i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS foe <br /> n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation A Dia. of Well Casing <br /> C1 S <br /> Domestic/Private R(Gravel Pack O Tracy Type of Casing PJ L pecifications <br /> 6 <br /> Aw <br /> I'I Public (:1 Other Cl Delta Depth of Grout Seal 3S AA OX) Type ofrout <br /> I I Irrigation S Approx. Depth I I Eastern Surface Seal Installed by_0 60 1 LL AA <br /> Repair Work Done U Type of Pump H.P. <br /> State Work bone <br /> Well Destruction O Well Diameter <br /> Sealing Material A Depth <br /> Depth Filler Material i Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I (No septiclable i stemin rented if public sewer is <br /> avaInstallation will serve: Residence_ Commetcisl_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to i depth of 3 feet: Water table depth <br /> SEPTIC TANK O Type/Mfg - Capacity_ No. Compartments <br /> PKG. TREATMENT PLT.❑ Method of Disposal <br /> Distani�to nearest: Well Foundation Property Line <br /> LEACHING LINE O No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well f=oundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS O <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: "1 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 of sub-contracting signature <br /> certifies the following:"I certify that in the performsnee 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 applican ust call for all required Inspections. Complete drawing on reverse side. <br /> Signed Title: _�LL'7 r wj sVy►T, Date: yO <br /> FOR DEPARTMENT USE ONLY �J f� C/ <br /> `" Datb l r �I Area r t DIY 7,�- <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies tot San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Razelton Ave.. P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO �^ CASH '(c� <br /> . EH 13-24(REV,I/n 51 �-t �s m ' ► ( o <br /> EH .4-20 C� <br />