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APPLICATION FOR PERMIT <br /> 1 � <br /> _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> t ENVJRONMENTALCHEALTH DIVISION <br /> 1601 E.' HAZELTON AVEC , PHONE (209)4Z8-3420 . 1 <br /> V' P O BOX 2009, STOCKTON, CA 95201 <br /> � . <br /> MWIT <br /> EXPIRES 1-YEAR FROM DATE ISID <br /> (Complete in 'Triplicate) 1P <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the work heiein described. This <br /> application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address , Cit Lot Size/Acreage <br /> t <br /> Owner's Name Ir fiQMsD`Id Address r• Phone <br /> "101 <br /> Contractor Address / Z 7 —License No. I ! r Phone <br /> TYPE OF WELL/PUMP. f4FW WELL 2---* WELL REPLACEMENT ;' DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION �� SYSTEM REPAIR ❑ OTHERS© Monitoring;Well C7 <br /> DISTANCE TO NEAREST: SEPTIC TANK lea '4- SEWER LINES 0/00 4" DISPOSAL FLD.ZjQt:�fPROP.'LINE _.tQ+ I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS A529 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION-SPECIFICATIO , rt <br /> nI�ndustrial © Open Bottom ❑ Manteca Dia. of Well ExcavaSi& Dia. of Well Casing <br /> l <br /> [WDomestic/Private WO'Gravel Pack ❑ Tracy Type of Casind-�_ - yG Specifications- L <br /> e <br /> I'I Public j C7 Other F1 Delta Depth of Grout eal" Type of Grout <br /> I I Irrigation __Approx. Depth I I astern Sur ce Seal Installsd•by ra <br /> RepairWork-Done': Type of'Pump - ' -'�`�-WP. State Work-Done_= <br /> Well Destruction Q Well Diameter <br /> Sealing Material & Depth <br /> { <br /> Depth - —Filler Matekal & Depth <br /> t c. 1 - <br /> TYPE OF SEPTIC'WORK: NEW INSTALLATION I 1 REPAIRIADDITI'Ohl itl DESTRUCTION l I (No septic system permitted if public,sewer is <br /> ' t �; available within 200 feet.I rr• <br /> InstallationwIrserve.�'Residence Commercial Other <br /> Number of living g uniis:-^. Number}of bedrooms ` <br /> Character of soil to a depth of 3 feet: F � 3 j Water table depth I. <br /> SEPTIC TANK ❑ Type/Mfg ( 1 27--Capacity No. Compartments . <br /> PKG.TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line s <br /> i <br /> LEACHING,'LINE D No. & Length'of lines I Total length/sire T! <br /> kFILTER BED E) Distance to nearestr_r- Well Foundation Property Line <br /> SEEPAGE PITS l I Depth �l* Size E Number <br /> SUMPS ----0—Distance±t_ornearest}_ Well <br /> Foundation Property Line <br /> DISPOSAL;PONDS' a r ?� <br /> I hereby certify that I have prepared this application apd that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rulesjand regulations of the San Joaquin County , <br />{ Home„owner d 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 /> r empld person in ch manner as to become subject to workman's compensation laws of California.” Contractor's hiring or subcontracting signature . <br /> certifiJ •the fallowing: ' certify that,in the performs f the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion ws of Ca'ornia <br /> The pplicant t or Compl e drawing on s,d% <br /> Signe Title: r Date: 940 <br /> OR,DEPAFL EN.T,_USE_ONLY <br /> (.[/ + t <br /> Application Accepted by - Date Area <br /> Pit or Grout Inspection by Date Final Inspection by_ Date <br /> Z ao <br /> Additional Comments: ' P S I 3�� `��U <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> s Services, Environmental Health Permit/Services <br /> t 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE i <br /> j INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. <br /> y . EH 1321(REV.1/x5) <br /> EH 14.20 �. <br /> j <br />