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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FRQM DATE ISSUED <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 trade in cowpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin CountyPublicHea�lth Services. c. � A <br /> IV Job Address .�7 F T �"_X 00 _ City tom!� � Lot Size/Acreage <br /> �. v C-'M /�/D �Jl �i2 S/-`7?61- r <br /> Owner's Name �j Addres/s� �7 �7 Phone 7 /l <br /> Contractor �`"" Address '+' /. ._ License Nyr7� Pho'F70LY IS <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIONXOut of Service Well ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 112kz) <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F) Industrial C3 Open Bottom ❑ Manteca Dia. of Well Excavation l` Dia. of Well Casing <br /> %i�eOomestic/Private VGravel Pack ❑ Tracy Type of Casingle*!g.- Specifications 0!_�_ y <br /> I'1 Public fa Other (l Delta Depth of Grout Seal ZVa Type of Grout. C±n�eA - <br /> I I Irrigation -L,4J13_ Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 12 Type of Pump — H.P. Z.. State Work Done <br /> Well Destruction ❑ Well Diameter to, Sealing Material b Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.j <br /> Installation will serve: Residence--.:- Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �l <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE C1 No, & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line zt <br /> DISPOSAL PONDS ❑ <br /> 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 /> ti <br /> The applicant must call for all required insPections. Complete drawing on reverse side. <br /> Signed X_ -� Title: .dl&,±J*"— _„ Date: 04--L� <br /> FOR DEPARTMENT USE ONLY �j l� <br /> Application Accepted byL Date �� ` y Area <br /> Pit or Grout Inspection by Date Z� 0 Final I s action by ' Date�. <br /> Additional Comments: � / ���u �ZO� <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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY /'� DATE [�P.ERMITNO. � �/ <br /> . EH"C24IREV.iins� ,Q \����QI V`_f Y l Cj �y�D ` �+ 3 lam+ -. <br /> EH 4b24 1 � f/p <br /> v' <br />