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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3.603- E. HAZELTON AVE. , PHONE (209)46$-3420 t <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> 41?[U T T EXP I RES 1 YEAR FROM AT <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. <br /> S <br /> e• City Lot Size/Acreage <br /> Joh Address r <br /> Owner's Name U[� <br /> rn '0eVe 0 M@ Address _ 2- '" _ Phone <br /> sue l ,�teo( ,2a?4� License No. �~�S Phone S 17� X39 <br /> Contractor Q 1.. uN' ,t Address w <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR C7 <br /> OTHER ❑ Monitoring Well L7 <br /> I DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES - %DISPOSAL FLD. PROP, LINE <br /> FOUNDATION- __� AGRICULTURE WELL _OT'.HER_WELL PITS/SUMPS <br /> f INTENDED USE .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing s� <br /> 1111 n Industrial Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing 'e Specifications <br /> ip Domestic/Private LGravel Peck C] Tracy YP t 9 Type of Grout f <br /> 3-'I Public Cl Other C1 Delta Depth of Grout Seat <br /> k <br /> I i Irrigation i Approx. Depth I i Eastern Surface Seat Installed by <br /> I .'J -State Work Done _ <br /> Repair Work Done 0 Type of Pump H.P. 3 <br /> i Sealing Material k Depth <br /> Well Destruction © Well Diameter Filler Material & Depth�N: <br /> Depth 4 <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION l I REPAMIADDITION I I DESTRUCTION I I (No septic systemithin rented if public sewer is <br /> Installation will serve: Residencef Commercial ""Other <br /> i r <br /> Number of living units: f Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: - <br /> l ti Capacity No. Compartments <br /> SEPTIC TANK. ❑ TypelMfg <br /> PKG. TREATMENT PLT. 0 k `4. Method of Disposal <br /> Distance to nearest: Well' ""Foundation - ,Paroperty Ln s <br /> i } <br /> LEACHING LINE ❑ No. & Length of lines _ Total length/size <br /> t iProperty Line <br /> FILTER BED CI R Distance to nearest: Well Foundation <br /> SEEPAGE PITS 11 T Depth Size Number C <br /> SUMPS L1 r Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ <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 /> I 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." 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." I <br /> The applicant ust call for all required inspecti s. Complete draw' g on reverse side. <br /> Signed <br /> Itle: f7 , 1 - - Date: 7 <br /> 7 LZ <br /> FOR DEPARTMENT USE ONLY <br /> ' Date Q Area <br /> Application Accepted by 7 <br /> Pit or Grout Inspection by Date 1 Final Inspection by Date <br /> Additional Comments: l3� <br /> Applicant - Return all copies to: San Joaquin County Public Health 1 <br /> Services, Environmental Health Permit/Services` <br /> 1601 E. Hazelton Ave., P x 2009, Stockton, CA 95201 <br /> FEE CK RECEIVED BYZC�)ATE PERMIT'NO. 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED SH _ rj <br /> EH 13.24{AEV.I/K SI r/ `^ <br /> EH:4.26 <br />