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APPLICATION FOR PERMIT <br /> `'`�' vtA•Lt�^ <br /> 7 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 /> Oct �PTiRYTT EXPIRES 1 YEAR FRO DA E EID <br /> "t (Complete in Triplicate) <br /> f <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 Servicers. j <br />` p c>1 City !!2i IV hot Size/Acreage i <br /> Job Address <br /> L Address Phone <br /> Owner's Name � <br /> i yy <br /> e n�� <br /> .d.Address - <br /> / !+'R)`•fo'`' R� License No.y�-Phone <br /> Contfactor �- <br /> TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L) Out of Service well LJ <br /> Monitoring well C3 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER C) <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 Well Casing <br /> Ll Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation <br /> Type Casing Specifications <br /> �omesticlPrivate ❑ Gravel Pack ❑ Tracy of Cg Type of Grout <br /> I'1 Public C) Other n Delta Depth of,Grout Seal <br /> I I Irrigation Approx. Depth I I Eastern Surface-Seal Installed by <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> & <br /> Well destruction ❑ Well Diameter Sealing Material Depth 1� <br /> Depth Filler Material 5 Depth <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION EPAIR/ADDITION l I DESTRUCTION I I availableseptic <br /> w thin 200 feet.) it public sewer is <br /> Installation wilt serve: Residence—Commercial— Other <br /> Number of living units: Number of bedrooms 2L2 -- <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK 0-'Type/Mfg =1_ Na. Compartments <br /> PKG, TREATMENT PLT. CI of Disposal <br /> Distance to nearest: Well Foundation PropertyE Line q <br /> ° ' Total length/size - <br /> LEACHING LINE Cl No. & Length of lines,f i ° <br /> FILTER BED n Distance to nearest: �, ^Well Foundation Property Line <br /> t SEEPAGE PITS 11 Depth �x" Si._ — Number <br /> SUMPS Cl 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 I Iy <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 <br /> empipy 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 per is issued, 1 shall employ persons subject to workman's compensa- <br /> tion laws of Californle." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed j' ' Title: Oa Date: 7` <br /> ' R x <br /> F MENTIUSE ONLY �y <br /> Date r Area <br /> Application Accepted by c, 6[9 q 0 <br /> r Date `L <br /> Pit or Grout Inspection by Date Final Inspection by <br /> 5 - <br /> t Additional Comments: , <br /> 1 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 /> fEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERM17'NO. <br /> INFO CASH d 0; <br /> . f�13.241 .tin51 roc? foD SUZY t 7 <br /> fi •EW 14-26 <br />