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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 /> RES 1 YEAR FROM "AMV <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application is made in�e compliance withuin SanOounty Joaquinor a CountyrOrdinancemit to nstruct 110. 549 and 1862andtheeRules andeRegulationsdof Sans <br /> application is �P <br /> Joaquin County Public Health Services. <br /> Cit Lot Size/Acreage <br />' Job Address <br /> .,S C� 1S E 1 . Phone <br /> Owner's Name r/ y dress <br /> t` 4f47,�Xc�..� � -Phone -,23 3 <br /> Contractor GL * l ddress License IVo: <br /> of Service Well <br /> TYPE OF WELL/PUMP: _ NEW ELL C] WELL REPLACEMENT 0 DESTRUCTION Out L1 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR ❑ <br /> OTHER ❑ Monitoring Well €3 <br /> '" DISPDSAL FLDPROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES . <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia, of Well Casing <br /> C1 Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation <br /> Specifications_ N <br /> Ca Domestic/Private MGravel Pack ❑ Tracy Type of Casing Type of Grout (V <br /> I`1 PUblic fa Other I Delta Depth of Grout Seal w <br /> I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by <br /> Of Pump WP. State Work D e <br /> Repair Work Done U Type sealing .Material & Depth <br /> Well Destruction © Well Diameter _ {� <br /> - Depth Filler Material 8 Depth ,rA t <br /> 0}..n' <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION { I DESTRUCTION I I (No septrwihin 200 feel-1, if public sewer is <br /> y }y i► �� <br /> a +� <br /> ' I stallation will serve: Residence— Commercial— Other <br /> Number of living units; Number of bedrooms <br /> i Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i t Method of Disposal <br /> f PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> ,i <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest Wall Foundation Propeny Line <br /> SEEPAGE PITS 11 Depth % `""Size Number <br /> SUMPS LI Distance to nearest: Well 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 applicant must call for all required ' s ions. Complete drawing on reverse side. * b <br /> Signed X Title: Date: �G <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by <br /> Date v Area <br /> Pit or Grout Inspection by Date�-_-__��. Final Inspection by Data <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 /> AL <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY OATS PERMIT'NO. <br /> INFO ,�y� �(�--- I <br /> . EH 13-24IREV,I/MS) V v t� t ©�h o ~� `��D �.p o,3 <br /> EH 94.26 <br />