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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> IP O BOR 2009, STOCKTON, CA 95201 <br /> EXPIRES 1 YEAR-poll ve 10.p M DAT <br /> 0 (Complete in Triplicate) <br /> I work <br /> Application is hereby made to San Joaquincounty <br /> County mitOrdtonconstruct 5l+9gand 1t362sand theeRules and Regu]ationsdof Sans <br /> application is made in compliance <br /> J� �is NP-bljVealt1,,,,.a J 1; <br /> /QQl � ��•r " j �Z - Lot Size AcreageJobAddresPhone <br /> Owner's NaAddress <br /> t/t cense No PhoneC. Address r C d Q <br /> Contractor , f� DESTRUCTION 0 Out of Service Well ❑ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL.REPLACEMENT C] Monitoring Well <br /> SYSTEM REP.AiR OTHER ❑ <br /> PUMP INSTALLATION ❑-- t` <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC.TANK PITSlSUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing I <br /> C] Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> F Domestic/Private ❑ Gravel Pack C] Tracy Depth of Grout Seal Type of Grout <br /> i"1 Public S 1 Other i Cl Delta 1 <br /> I Irrigetion .Approx. DB t tEastern Surface Seal Installed by g . <br /> t of Pump <br /> N.P. State Work Oone O <br />`- Repair Work Donee 0 TYPE <br /> ,t � Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter g#liar Material & Depth <br /> ' Depth <br /> .s s <br /> TYPE OF SEPTIC WORK: NEW.INSTALLATION I 1 REPAIRlADDITION { I DESTRUCTION l I availablerwthin 200 feet.) if public sewer is <br /> Installation will serve: Residence— Commercial_ Other — <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of-3 feet' No. Compartments <br /> SEPTIC TANK ❑ TyO/Mfg Capacity <br /> I Method of Disposal <br /> PKG. TREATMENT PLT. ❑ � ^ i Property Line <br /> Distance to nearest: Well Foundation <br /> Total length/size— <br /> LEACHING LINE ❑ No..& Length of lines Property Line <br /> FILTER BED CO-Distance to nearest: Well Foundation <br /> Sire -, . K Nur'bari� <br /> SEEPAGE PITS I I Depth ,--�^-�*praperty_Line - <br /> SUMPS 0 Distance':to'nearesu =Weil -- - �..:.Foundation'^"- <br /> DISPOSAL PONDS ❑ �" <br /> I hereby certify that I have prepared this.ajiplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> nor <br /> rules and regulations of the San Joaquin County <br /> ollowing: "I certify that in the performance of the work for which this permit is issue <br /> Home owner or licensed agent's signatufe',certifies the fd, l shall mpensation laws of California." Contractor's hiring of sub contracting signature <br /> employ any person in such manner as to become subject to workman's co <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." <br /> f The:ppli ust It for all requ' spect' s. Co lets drawing an raver e, `0 Date: <br /> Signd Title: ._- <br /> Ae <br /> i J.OR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by r <br /> Data <br /> { <br /> I Final inspection by �~ ' <br /> Pit or Grout Inspection by f Date — <br /> Additional Comments: <br /> Applicant - Return all copies to.t$an zoaquin County Public Health <br /> h%Services, Environmental Health 2009,PermiStockton, <br /> (`1601 E. Raaelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> CK RECEIVED BY DATE PERMIT NO. <br /> I lFEEO AMOUNT DUE AMOUNT REMITTED CASH <br /> I _�b q0- <br /> + EH 13-24IREV.r/Ksl <br /> EH 24.2E <br /> I <br />