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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)46$-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> RUIT EXPIRES 1 YEAR FROM DA ED <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 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health St <br /> qX73 . ;%;_Q_ r Job Address � City Lot Size/Acreage <br /> Vlowner's Name Pu S Address L?73E] Phone X— <br /> contractor IU-61=%dress q [ 73 EL`(n��1-tG -License No. Phone <br /> TYPE OF WELL/PUMP:I NEW WELL © WE REPLACEMEF DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ STEM REP IR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE N I DISPOSAL FLD. PROP. LINE <br /> t FOUNDATION AGRICULTURE W L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTACTION SPECIFICATIONS <br /> f_� Industrial ❑ Open Bottom ❑ Manteca .—Dia. o(WeExcavation Dia. of Well Casing <br /> f:} <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casin Specifications <br /> h'i Public fa Other n Delta Depth of Grout eal Type of Grout <br /> I I Irrigation _Approx. Depth I i Eastern /Surface Seal In'I d by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Se ling Material & Depth <br /> Depth /11 Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIOFK OESTRUCTION 11'INo septic system permitted if public sewer is _ t <br /> available within 200 feet.) <br /> Installation will serve: R idence Commercial Other <br /> Number of living units: Number of be rooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. 0 Type/Mfg fX7,3,V rJ Capacity No. Compartments t <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well U I Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Fou a on Property Line <br /> L K. <br /> SEEPAGE PITS 11 epth Size 4X Z-) Number ( DI�S", I <br /> j LIMPS Iristance 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 <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 notes <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: "1 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." <br /> The applicant t ca for r uired inspections. Complete drawing on reverse side. AUA <br /> }SiJli� gned X Title: Q 1 Date: CIJ <br /> R DEPARTMENT USE ONLY <br /> Appli ion Accepted by nZ . . Date �� Area — <br /> r rout Inion by Date — = Final Inspection by� e �� <br /> Additional Comments: <br /> ) <br /> Applicant --Return all copies to: San Joaquin-County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE A UNT REMITTED 'SASH AECEiVED BY DATE PERMIT NO. <br /> INFO <br /> t V l <br /> . EH 13•24 IREV.1/n 5f ;rye I ' ( �` <br /> EH a�•20 V V 1 <br />