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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)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> pgMIT RES 1 YEAR FROM DA En <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 1$62 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> }�g25 City Lot Size/Acreage <br /> Job Address <br /> /,�O � Iql 7 <br /> Owner's Name..— 4 Address Phone!J7 tl <br /> r .7f -Z(- phone <br /> Cantrac <br /> � uJ Address � � + r License No. <br /> Out of Service Well ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C1 <br /> SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 <br /> PUMP INSTALLATION C] <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, <br /> LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i (1 <br /> ❑ Industrial ❑ Open Bottom [1 Manteca Dia. of Well Excavation Dia. of Well Casing �J <br /> Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing -r Specifications <br /> F1 Public F1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation —..Approx. Depth t I Eastern Surface Seal Installed by 'h <br /> Repair Work Done U Type of Pump H.P. State Work Done <br /> Well Destruction EJ Well Material & Depth Well Diameter <br /> Depth Filler Material & Depth <br /> 7Y—PE OF OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I i DESTRUCTION l I (No septic system permitted if public'sewer,is <br /> availab within 200 feet.) <br /> Installation will serve: Residence Commercial-K Other <br /> Number of living units: Number of bed oms - � <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Ca acit No. Compartmenfs­ <br /> SEPTIC TANK. �TypelMfg P Y��-�-- _ - <br /> PKG. TREATMENT PLf ❑ (.�- /� Method 6f Disposal <br /> Distance to nearest: Well Foundation ! Property Line. 'FT <br /> i. LEACHING LINE /)K.,No. & Length of lines �Aot To,al length/size t^ r <br /> r FILTER BED E) Distance to nearest: Well �� Foundation , Property Line�,,�� <br /> � F <br /> SEEPAGE,Pits Depth s Size "'' Number t A <br /> r� <br /> SUMPS CI {Distance to nearest: - Well_1Q Foundation Q } Property Line ^— <br /> r DISPOSAL PONDS ❑ <br /> fl 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 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." <br /> Theapplicant m call for qui d inspections. Complete drawing on reverse id <br /> Signed X Title: �> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 4 ! Area <br /> Yor Grout Inspection by 4paU-VDate - - Final Inspection by �' r Date <br /> t <br /> Additional Comments: <br /> j Applicant - Return all copies to: San Joaquin County Public Health <br /> i r Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO ` 1 <br /> rEH13-24IREV.t/a51 �il.k�^-" L q` � <br /> EH A .25 <br />