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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I d ° ENVIRONMENTAL HEALTH DIVISION <br /> X601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> ' P 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISPUED <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 /> i Joaquin County Public Health Services. <br /> / / I I <br /> Job Address _CP-3-T� � ' `�� Q — Cit Lot Size/Acreage „ Od�X 22 -_ <br /> r <br /> �� �v. �S�/ yra�FQ F Phone JsJL77 <br /> Owner's Name ,� � , � dress _ --- _. .� <br /> Contractor 1lGL_7z / Gl Address License too,/ Phone <br /> 46 Z 46Z. <br /> TYPE OF WELL/PUMP: NEW WELL 5K WELL REPLACEMENT DESTRUCTION Out of Service Well D <br /> PUMP INSTALLATION SYSTEM REPAIR Cl QTA,4�EF� O <br /> Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _Z-6�0� -tom� SEWER LINES �-�� �" DISPOSAL F1.40172912--1 <br /> LD. ^ PROP. LINE <br /> FOUNDATION — =— AGRICULTURE WELL OTHER WELL_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION ' u <br /> Cl Industrial ❑ Open Bottom [D Manteca Dia. of Well Excavation Dia. of Well Gasin O <br /> [domestic/Private 5KGravel Pack ❑ Tracy Type of Casing Specifications <br /> I'] Public Ell Other �I n Delta Depth of Grout Seal OF Type of Grout <br /> M I I Irrigation 1,00.Approx. Depth 4efastern S�+rface Seal Installed by. <br /> i <br /> Repair Work Done 0 Type of Pump H.P. State ork Don f S <br /> � <br /> I _e / -� I Sealing Naterial & Depth <br /> Well Destruction 1� Well Diameter i <br /> Depth r Filler Material & Depth 47 _ <br /> + TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I _ DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feet.M <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 <br /> SEPTIC TANK. ❑ Type/Mfg Capacity ,No. Compartments <br /> l <br /> PKG. TREATMENT PLT. ❑ ,. { Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size - <br /> FILTER BED ❑ Distance to nearest. Well Foundation Property Line <br /> F 5 <br /> SEEPAGE PITS 11 Depth �{ Size Number <br /> SUMPS C1 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, stati3 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 /> employanif <br /> manner as to become subje o workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies thotlowing: "I ce ify that in the e o the'work for which this.permit is issued,.l shall employ persons subject to workman's compensa <br /> G. tion laws Califor ia." ?. <br /> The app cant m o all req omple drawing <br /> Signed. � Title: .� .�� Date: <br /> ?30 fro <br /> r ' <br /> _USE ONLY <br /> I Application Accepted by nl,, CN-� Date 70 Area <br /> Date 7 q Final Inspection byData <br /> Pit or Grout Inspection by <br /> Additional Comments: Zw <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH gRECEIVED BY DATE C�PERMIT/•NGO. <br /> a EH13.24(REV.I/Is5) ^_) <br /> EH 14.26 <br />