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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTR 'SFRVICES <br /> ENVI RONMENTA,V _HEALTH DIVISION <br /> 16E. <br /> BOX 2009, STOCKTON, CAPHONE 952011 <br /> l <br /> gpII2ES 1 YEAR FR M DAT � , <br /> k (Complete in Triplicate) f <br /> and/or install the work herein described. This <br /> Application is hereby made.to San Joaquin County for a permit to construct <br /> n County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> application is made in compliance with San ,7oaqui { <br /> Joaquin County Public Health Services. <br /> Z "�fLot Size/Acreage City ` <br /> Joh Addres� <br /> ` �.• Phone <br /> Owner's Name - — Address <br /> i <br /> Contractor s Address <br /> 3+� �s \G, \,t - License No�'�? c% Phone <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ put of Service We11 ❑ <br /> TYPE OF WELL/PUMP: OTHER 54 Monitori>1�We�l r �� i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl �16A+JDt+J _ • � 1ypCE <br /> DISPOSAL FLO. I PROP. LINE a <br /> DISTANCE TD NEAREST: SEPTIC TANK SEWER__ SEWER LINES -- + PITS/SUMPS <br /> AGRICULTURE <br /> FOUNDATION WELL OTHER WELL L <br /> CONSTRUCTION SpECIFI��TIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA <br /> Dia. of Well Casing LQ�— <br /> C1 Industrial ❑ Open Bottom 0 Manteca Dia.-of Well Excavation <br /> Type of Casing �S Specifications <br /> D Domestic I Private D7 Gravel Pack C7 Tracy ��C'iC��-� _ Type of Grout SS --- <br /> I,d Public 1-1 Other r Delta Depth of Grout Seal <br /> b4 Irrigation __,.Approx.fDepth l I Eastern Surface Seal Installed by <br /> of Pump- H.P. State Work Done _ <br /> Repair Work Done f7 Type p Sealing Material & Depth <br /> Well Destruction ® Well Diameterf Filler Material & Depth <br /> Depth <br /> c system <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIAIADDITION I I DESTRUCTION I I avaiiabpelw thin 200 feetft`ed if public sews is <br /> Installation will serve: Residence—I� Commercial Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments <br /> SEPTIC TANK. © Type/M101 Capacity- -- Method of Disposal <br /> PKG. TREATMENT PLT. Cl _ <br /> 4 Distance to nearest: Well <br /> Foundation Property Lina <br /> f I ' <br /> Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Wellnceito nearesFoundation <br /> Property Line <br /> FILTER BED Cl Dtat: <br /> ';; ------------ <br /> t.- Number <br /> SEEPAGE PITS 11 Depth( S11e ! Property Line <br /> SUMPS L1 Distance'to nearest: Well Foundation s Y <br /> I if <br /> DISPOSAL PONDS ❑ <br /> that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and <br /> }� rules and regulations of the San Joaquin County <br /> llowing, "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the to <br /> employ any person in such manner as to become subject to workman's compensation laws of California." ploy cersrons+sub subject to workman's sub-contracting <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ p I <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse ide. <br /> r " Tiller Date: <br /> n2 7 1t tS 5�._ <br /> Signed <br /> ' FOR DEPARTMENT USE ONLY 7� res <br /> j .Date !6 <br /> I Application Accepted by . ./� <br /> I Pit o Grout epection by <br /> Date�!'L; J ' Final Inspection by Date <br /> Additional Comments: <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 /> ffFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> a EH 13-24 iREV.I/n 6) <br /> EH 14.2e <br /> 1 <br />