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APPLICATION FOR PERMIT � fS`'"0 Q I <br /> SAN JOAQU I N COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION SEP 1 8 492 <br /> 1601 E. HAZELTON AVE. , PHONE (209)46$-3420 . <br /> P 0 BOX 2009, STOCKTON, CA 95301 O 1(ON V WA❑1L'HEALTH <br /> PERMIX RFs YEAR R jKD PERMIT/SER ICES <br /> (Complete is Triplicate) <br /> Application ie hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> Application is made in cuzwllance with San Joaquin County Ord onance No. 549 and 1662 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> • aJ LLL_� <br /> Job Address j i � City LK�— Lot SIze/Acree <br /> Phone <br /> I <br /> I ' <br /> Cwner's Names <br /> b <br /> r� II <br /> COhtlaCtQ! ' AddressA&/ Chis No:t3��Phone <br /> TYPE OF WELLIPUMP: MEW WELL ❑ WELL REPLACEMENT LlDE5TRUCTION ❑ Out of Service We11 Cl r <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C1 monitoring Well �-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ❑1SPOSAL FLf7. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSJSUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C_ONSTRUCTiD_N SPECIFICATIONS <br /> ❑Industrial ❑ Open aottorrt ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' <br /> _ [a Domestic/Private ❑ Gravel Pack. - La Tracy Type of Casing _ Specifications <br /> i1 Public 11 Other I F1 Delta Depth of Grout Sea[ _ Type of Grout 11 <br /> IifiUation __ Approx.jDepth I I Eastern S e Seal installed by <br /> "JR"pair Work Done L7 Type of Pump# H.P. State Work Done <br /> Wolf Destruction ❑ Well Diameter Seal ; Material & Depth <br /> Depth ' f Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION E 1 REPAIR(ADDITiON I I DESTRUCTION I I INo septic system permitted if public sews{ is <br /> available within 200 fast.) <br /> Instal)a►ion will serve: Residence— Commarcial— Other <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: T Water table depth <br /> SEPTIC TANK ❑ Typel Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE D No. & Length of tines Total length/size <br /> FILTER BED CI Distance is nearest: Well Foundation . Property Line <br /> SEEPAGE PITS 11 Depth !� Size Number . <br /> SUMPS L1 Distance intf nearest; Well Foundation Property Line <br /> DISPOSAL PONDS D •l , <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."Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for whish tFiis permit is issued, I shall employ persons subject to workman's compensa- <br /> von laws of California." <br /> r^ <br /> The applicant m t c 11 fa qu' specfio Co eta dr ing on rev e e. <br /> Signed X f itis: _� Hate: <br /> t <br /> _ <br /> OR D T ONLY <br /> Application Accepted by Date � <br /> L Pit of Grout Inspection by Date Final inspection by Datg! <br /> Additional Comments: <br /> • r <br /> Applicant – Return s.11 copies to: San Joaquin County Public Health <br /> Services, Environmental health Permit/Services <br /> 1601 E. Hazelton Ave., P 2009, Stockton. CA 95201 <br /> i <br /> E A UN7 17U1 AMOU T REMITTER K RECEIVED BY TE PERMV7 Nt7. <br /> IN 0 <br /> . EM E3-241REV.rens � • � ' <br />