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APPLICATION FOR PERMIT <br /> V - <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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address 3 n N /L/f,xy City oOC C. Lot Size/Acreage <br /> t <br /> Owner's Name ES CF.wF_"?` 60-0p i Address ao Phone <br /> Contractor (l�,l(��%0 Address PU, l��/J/���License No�/5.�`D.2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <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 /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C.l Domestic/Private D Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I') Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Lr <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth _ Filler Material & Depth (7 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION lyd REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will,serve: Residence_ Commercial_ Other__U'F7cl_,'s <br /> Number of living units: Number of bedrooms —"—� <br /> Character of soil to a depth of 3 feet: �4,4 ci - ` rr/�' ater table depth <br /> SEPTIC.TANK ❑ Type/Mfg �.t J_ Cap city.�4!V99 o. Compartments <br /> PKG. TREATMENT PLT. ❑ �� Method of -Disposal <br /> Distance to nearest: Well tion Property Line Y' <br /> LEACHING LINE No. & Length,of.ines ­60 /' Total length/size <br /> FILTER BED O Distance to <br /> / :re4st: Well o n Property ne <br /> izeSEEPAGE PITS II Qeptf� <br /> y _ Number IL <br /> SUMPS ` Distance to nearest, Well Foundation, �� Prop Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 of licensed agent's signature certifies the following: "1 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 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 Iaws'of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. p <br /> Signed X Title: . Zd6 Dater <br /> -FOR DEPARTMENT USE ONLY �! / <br /> /111�� � f0 <br /> Application Accepted by Date 2L �� Area <br /> Pit or Grout Inspection by Date ' Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health 1 <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH 1RECCE,,, <br /> A I(((V'''E��� T'D BY DATE PERMINO. <br /> EH -21(REV s <br /> .�ixsi 1 � y \ � yL]{ 7`�p1 <br />