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APPLICATION FOR.PBRMIT <br /> 3SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1601 S. 'HAZELTON -AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PEM <br /> IT EXP RF 1 YEAR FROM DATE ISZSUED <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 Ordin ce No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> .lob Address �- CityLot Size/Acreage <br /> n <br /> Owner's Name ��G��S -�„�e� � Address _��,,A^ L� ---- -- Phone <br /> Contractor Addressa1��<, �-�_ License N Phone <br /> TYPE OF WELL/PUMP: NEW WELL Cl 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 /> ! ❑ industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing <br /> r ?Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ! I'I Public CI Other 11 Delta Depth of Grout Seal Type of Grout <br /> 1 I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by 42 <br /> Repair Work Done Type of Pumper H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION i I lNo septic system permitted if public sewer is V� <br /> t available within 200 feet.) <br /> Installation will serve: Residence `4 Commercial— Other <br /> f' 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 /> PKG. TREATMENT PLT. ❑ �L Method of Disposal <br /> Distance to-nearest: ell-_, t- -Foundation-L' Y 'Property Line <br /> 7. <br /> r . . <br /> LEACHING LINE ❑ No. &-Length of-lines _ Total tang[h/size^'� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line , <br /> i SEEPAGE PITS IJ Depth 1. Size) t. �a�='1 j Number <br /> SUMPS L! Distance to nearest: Well "Foundation Property Line <br /> i <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the,wnrk.will be done in'accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County I <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 /> I 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," r <br /> The app)' ust all for at! required ' trio omp to drawing on to rse side. <br /> f� <br /> SignedX Title: r� Date: <br /> i flTMENT USE ONLY <br /> Application Accepted byt. Date ? 1Z-''[ T� 1� Area <br /> ` Pit or Grout Inspection by Date Final Inspection byy Date ( <br /> Additional Comments: <br /> ,Applicant - Return all copies to:�San Joaquin County Public Health ; <br /> �. , Service's, -Environmental Health Permit/Services <br /> 1601 E. Razelton Ave., F 0 Bok-2009;—'Stockton, CA 95201 <br /> 5 <br /> i INIF <br /> EE*5` 05 <br /> OUNT DUE AMOUNT REMITTED SASH �� flECEIV..Ep BY DATE PERMIT'N0. <br /> I <br /> . EH 17.24 UtEY.tinsi EH A.26 ' L—Li­k WJ L V+ 1 <br /> 1 <br />