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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1'601 E. gAZELTON AVE. , PHONE (209)468--3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> �rr..,rm EXPIRES 1 YEAR FROM DAT —1 <br /> (Complete in Triplicate) <br /> work <br /> in <br /> Application is hereby compliance Joaquin <br /> ithal m ounty Joaquinor a County Ordinanceermit to nstruct No. 549asndo1862$taLl and theeRules andeRegulationsdoi Sans <br /> application is made in comp I <br /> Joaquin County Public Health Services. r j <br /> I <br /> � ' QD City • / ^—t Lot Size/Acreage <br /> .fob Address -ce-�- 4 <br /> t <br /> ,� Phone <br /> Owner's Name �--_-T _- — Address <br /> Contractor -• ��� <br /> _Address 1re4174-A—License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service well ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />' iNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Weil Casing <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> C1 Domestic/Private ❑ Gravel',Pack n Cl Tracy <br /> Type of Casing <br /> Cl Other t; ''° .n Delta Depth of Grout SealV1 Publi� <br /> Type of Grout <br /> I I lrriDat6i, —.Approx. Depth-t-I_Easlefn Surlace Seal Installed by (� <br /> Repair Work Done L3 Type of Ptitmp H.P.= State Work Done �✓� 1 <br /> Sealing Mate`risl & Depth <br /> Well Destruction C] Well Diameter <br /> f <br /> Depth Fi11eT Mstetial & Depth <br /> TYPE_7 SEPTIC WORK: NEW INSTALLATION t I ' <br /> BE )< DESTRUCTION I I availab e within 200 lseptic system e l.1i it public sewer is <br /> installation will serve: Residence Commercial— Other'— <br /> Number <br /> ther'Number of living units: __I— Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet:` <br /> SEPTIC TANK ❑ Type/Mfg,¢^` Capacity -- Na. Compartments <br /> PKG, TREATMENT PLT. ❑ /11 I Method of Disposal <br /> Distance to nearest: Well Foundation ),Property Line <br /> • _M <br /> TEACHING LINE No. & Length of,lineTota1"length/size-•-- <br /> ' 9` Foundation O - Property..tin' <br /> FILTER BED ❑ Distance-to nearest: Well ; a <br /> i _ Nu bar <br /> 11. i - _A 't <br /> SEEPAGE PITS I 1 Depth Size <br /> SUMPS f Ll Distance to nearest: Wel! Foundation?_� Property Line <br /> J f ;� t .�. Vc`• <br /> DISPOSAL PONDS C3 <br /> I hereby certify that I fiave prepared this application and that the work will be done in accordance with San Joaquin county-6rdinances, state laws, and <br /> i rules and regulations of the Spn Joaquin County l' <br /> 1 Home owner;or licens4agent's signature cenifies 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 t6 become subject to workman's'cornpensation laws of California." Contractor's hiring or sub contracting signature <br /> F certifies the fgllowing: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's'compensa- <br /> i tion Yaws of Californla.' ' u <br /> # The applicant must call for all r quire inspections. Complete drawing on reverse side. <br /> Title: pate: <br /> Signed >w, <br /> R.D RTMEN SE ONLY <br /> Application Accepted by G Date Are <br /> ll Pit or Grout Itspection by Date 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 �f T <br /> FEES —AMOUN"r DUE AMOUNT REMIT70.� <br /> `C RECEIVED BY DATE PERMITNO. _ <br /> ,INFO,. t1 s CASH- <br /> . EH 13-24 tR£V.I1$5) { Lj <br /> �O , �• �� •� �� � . <br /> EH 1625 1 _q. <br />