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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> rENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> i P 0 BOX 2009, STOCKTON, CA 95201 0 CT 9 8 iggn <br /> I EXPIRES 1 YEAR FROM 4NVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMIT/SERVICES <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> IncP . <br /> Job Address v City Lots-i2z�e/�Acreage �y <br /> Owner's Name f Address p Phone C <br /> Contractor <br /> J �[ r f AddressPdr/ZYI.'V&iZ ' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service He11 ❑ <br /> PUMP INSTALLATION © SYSTEM REPAIR L7 OTHER �- <br /> 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 /> n Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C <br /> Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing Specifications <br /> I'I Public C] Other ' I1 Deli th of Grout Seal a Dep <br /> a' Type of Grout <br /> I I Irrivation —„APProx.'iDethI I Eastern: Surface-Seal installed by.-- <br /> Repair Work Done (Y- Type of Pump H •P• State orkFDane <br /> Well Destruction ❑ Well Diameter Se ing Material & Depth. <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.), <br /> Installation will serve: 'Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth l� <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ v� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED n Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS LI Distance to nearest: - Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that t have prepared this application-and the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County L1,” - r <br /> f Home owner or licensed agent's signature certifies the following: '.'f certify that.in the performance of the work for which this permit is issued, l 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 laws of California." s l - - I <br /> The applicant must call fora squired inspections. Complete drawing on reverse side. <br /> i' Signed (/ Title: Date: f� <br /> I FOR DEPARTMENT USE-ONLY t <br /> Application Accepted by Date -- `��� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: `! <br /> Applicant - Return all copies to: $a.n Joaquin County Public Health <br /> iServices, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> i <br /> CKS <br /> FEE AMOUNT DUE:I AMOUNT REMITTED A-SW RECEIVED 8Y DATE PERMIT"NO. <br /> INFO <br /> . EH 13-24 PIEV.I/)is) �,� i � b'-�- o <br /> EH 34.20 <br /> r <br />