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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONir1ENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT XP RES 1 YEAR EROM DAIR 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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address City Axel, �d,ot Size/Acreage <br /> Owner's Name a+{ ,✓�%P " — Address GG Phone <br /> �� f Phone <br /> Contractor Address P � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 <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 /> P Industrial C1 Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"l Public [-1 Other n Delta Depth of Grout Seal Type of Grout <br /> 1 t Irrigation _Approx. Depth I i Eastern Surface Seal Installed by <br /> Repair Work Done (3 Type of Pump H.P1 State Work Done <br /> Well Destruction O Well Diameter Sealing Material & Depth <br /> Depth Filler Material b Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I- REPAIRIADDITION -'DESTRUCTION-I-1-hNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence,L Commercial J._.. Other <br /> Number of living units: _j____ Number of bedrooms sl <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D '�_ Method of Disposal <br /> Distance to nearest:. ` Well Foundation- Property Line <br /> Y 9 <br /> LEACHING LINE No. & Length of lines - -^ Total length/size - FM 2!5L <br /> FILTER BED ❑ Distance to nearest:I: Well Foundation Property Line — <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation l 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, (.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 issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ., <br /> The applicant must call for a requir inspect ons. Complete drawing on reverse side, <br /> Signed Title: Date: <br /> OR DEP TMENT U ONLY <br /> Application Accepted by Date a <br /> Pit or Grout Inspection by Date Final Inspection Date <br /> Additional Commirtts:' _ <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 RECEIVED BY DATE PERMIT'N0. <br /> INFO CASH `` Q <br /> a EH 13-24 MEV.i/M5) � .l 1 Q 1 L,9G <br /> EH x•26 <br />