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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 O 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. rjn <br /> Job Address IYL�/'ti//Y / City Lot Size/Acreage <br /> Owner's Name 'mJ 2 'hess Phone <br /> Y <br /> Contractor o Addres ' !h <br /> Licen e N4��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 /> .F <br /> INTENDED USE TYPE OF WELL PROBLEM AREA" CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .� <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications (�} <br /> FPublic [a Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> 10 <br /> I I lrrivation ,._._Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depthi Piller Material & Depth <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is {/� <br /> available within 200 (eel.I <br /> installation will serve: Residence�, Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of? feet: Water table depth <br /> SEPTIC TANK Type/Mfg 42:Ef' ' ..- Capacity_f:;R:__0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ I ! Method of Disposal <br /> Distance to nearest: Well _ Foundation 1 Property Line ---�✓ 1 <br /> LEACHING LINE - No. & Length of lines Total length/sire i <br /> FILTER BED. ❑ Distance to nearest: Well FouA. n tion�. Property Line 41O <br /> SEEPAGE PITS I 1 Depth Sire Number <br /> SUMPS` A `—� LA Distance to nearest: ti'well Foundation Property Line I <br /> t DISPOSAL PONDS 13 �I t I <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 <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 /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or subcontracting 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." I I <br /> The applicant must call for all required ins ctions. Gomp a drawin reverse side, <br /> 11 <br /> Signe itle: _sem]• _�___W_ Date: ��1 � <br /> F DEPARTMENT USE ONLY <br /> 51 <br /> Application Accepted by L Date Area G,r <br /> Pit or Grout Inspection by Ij Date Final Inspection by Date <br /> Additional Comments: I� <br /> i <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 <br /> INFO <br /> FEE AMOUNT DUE AMOUNT REMITTED �CASH RECEIVED BY DATE ZPERMIT'NO. <br /> EH �2B 1REV.irH5S 0ID <br /> 0 <br />