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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> i' ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> I t (Complete in Triplicate) <br /> Application is hereby made,to Ban 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 /> IJoaquin County Public Health Services. <br /> Job Address 'S)S _t'fn/f n _ City 6 Lot Size/Acreage <br /> Owner's Name I �h' 7�t ty Address E Phone <br /> o Contractor L11G2 Address -P /�c��lGf License No. .� SI Phone_ Q 'f�—o 9 <br /> TYPE OF WELL/PUMP: NEW WELL E] ., WELL REPLACEMENT ❑ DESTRUCTION VIL-Out of Service Well ' <br /> PUMP INSTALLATION ❑ i � <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICUL'_TURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca ' Dia. of Well Excavation Dia. of'Well Casing <br /> fa <br /> Domestic/Private ❑ Gravel Pack j ❑ Tracy Type of Casing Specifications <br /> i'l Public Ci Other f-1 Delta Depth of Grout Seal Type of Grout <br /> i I lrrigation _Approx. Depth ( I Eastern . i Surface Seal Installed by <br /> Repair Work Done U Type of Pump f C H:P. ate Work Do <br /> Well Destruction �L_ Well Diameter X Sealing Material & Depth <br /> Depth t Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRAd ITION_I_l_D.ESTRUCT,ION_l_I (No septic system permitted it public sewer is ' <br /> r �-'' 1 available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other !,� <br /> Number of living units: Number of bedrooms t 1f t <br /> e <br /> Character of soil to a depth of 3 feet: Water table depth -" <br /> SEPTIC TANK. ❑ Type/Mfg <br /> Capacity No. Compartments ' R <br /> M PKG. TREATMENT PLT. I_] ! I ti, Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines i l otal lerygth/sixe <br /> FILTER BED ❑ Distance to.nearest: Well _ Foundation Property Line <br /> i SEEPAGE PITS l I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <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`fohowing:•"I-certify-that-n-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 or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is-issusd, I shall employ persons subject to workman's compensa- <br /> tion laws of Califor <br /> t6 The applicant u t callforall requirednspecti s. Complete dr on re rse side. <br /> Signed X ills: Date: <br /> Qji PARTMEN E ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by Date F' al Inspection b r Dat <br /> Additional Comments: _ <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> I Services, Environmental Health Permit/Services <br /> _ 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO rr Q �q <br /> E 13-24 tREV.tiKSf O <br /> EHN 1,L4-291,L4-29 ©l <br />