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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES1 YEAR FBM 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 /> 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 /> r �— <br /> Job Address aid1�• � � - City Lot Size/Acreage (�C.�l - <br /> Owner's Name s✓� 5 Address `�L10 Phone <br /> �^ q � r�dr <br /> ^� Phone 23`t-Jl L4 2 <br /> Contract + r Address T,V'B" !10 License No. ZEZ Phone 6q V pS-- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION Ll Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 Monitoring Well c <br /> i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL-FLD. - - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial 0 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 17 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C1 Public i-1 Other n Delta Depth of Grout Seal Type of Grout <br /> i I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Dane <br /> Well Destruction s`❑ Well Diameter Sealing Material & Depth <br /> i Depth }* Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR! DDITION DESTRUCTION 11 (No septic system permitted if public sewer is <br /> available within 200 feet.1 <br /> Installation will serve: . Residence_ Commercial X Other <br /> Number of living units: Numbero edrooms I <br /> Character of sail to a depth of 3 feet: �tA zx lt,a4t�, _ 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 /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i ft <br /> SEEPAGE PITS Depth Size Number <br /> ( <br /> SUMPS L1 Distance to nearest: We" 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 became 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 applicanust calf all quired inspections. Complete drawing on reverse sid <br /> t <br /> Signed Title: _ _ �1 r_ r Date: ��✓ <br /> FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted by Date �L v LV- Area / 2-1 <br /> "r Grout Inspection by Datey�_ Final Inspection by Date�� <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 K 0 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> • EH 13-24 rREv-i i x srLA <br /> 7f� <br /> EH14-26 ��-L/ <br />