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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 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EXPIRES 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 />application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Elan <br />Joaquin County Public Health Servic <br />!b <br />r, AAA,e till + I i E . P iM 0 riTv?5?_4J E.1 Lot Size/Acreage <br />F wtiJ�ih iRGI 1���ti1txrLH-� Address 1 ( E. 1 (/V�Q +( r Phone <br />Owner's A ame <br />Contract ti Address. ]r r �. License No Z 77� Phone 67W -S-1 <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D Out of Service Well Cl <br />- -PUMP INSTALLATION O SYSTEM REPAIR O OTHER P Monitoring Well <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ___ DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL a OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br />n Industnal Cl Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing <br />C.l <br />Domestic/ Private 0 Gravel Pack 0 Tracy Type of Casing Specifications <br />"I Public is Other fl Delta Depth of Grout Seal Type o1 Grout <br />I I Irfigation —.Approx. Depth t I Eastern Surlaee Seal Installed by <br />Repair Work Done 0 Type of Pump H. P. _ State Work Done _ <br />Well Destruction C7 Well Diameter Sealing Material b Depth <br />Depth Piller Material b Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION IREPAIR/ DDITION,X, DESTRUCTION ( I Wo septic system permitted if public sewer is <br />r available within 200 feet.) <br />Installation will serve: Residence— Commercial K Other <br />Number of living units: Number of 4drooms t <br />Character of soil to a depth of 3 feet: Water table depth <br />SEPTIC TANK '&,� Type/Mfg l Capacity No, Compartments <br />PKG. TREATMENT PLT, El Method of Disposal <br />Distance to nearest: Well _.. Foundation Property Line <br />LEACHING LINE 0 No. 8 Length of lines Total length/size <br />FILTER BED 1-I Distance to nearest: Well Foundation Property Line <br />r rl <br />SEEPAGE PITS >I—, Depth .Size 'LAY q.,nber <br />SUMPS LI Distance to nearest: Well ! Foundation 0_ Property Line.. <br />DISPOSAL PONDS ❑ <br />U <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 />rubs 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, 1 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 ws to for alreq red ' spections. Complete drawing on revers`e�d \ Q <br />Signed X Title: v, Date: as` <br />/. FOR DEP RTMENT USE ONLY <br />.i <br />Application Accepted by / Data v Area—/ <br />/Pit,br Grout Inspection byDate y�/-SFinai Inspection by <br />Additional Comments: ' <br />Applicant - Return all copies to: San Joaquin County Public Health <br />EH 13-24 (REV, I/ n 51 <br />EH 4625 <br />Services, Eavironmental Health Permit/Services <br />1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br />FEE y� <br />INFO <br />i AMOUNT DUEAMbUNT <br />REMITTED <br />C 11 K <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT N0. <br />X <br />