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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 BOR 2009, STOCKTON,`CA 95201 <br /> i <br /> ESP RES 1 YEAR FRQM DATE ISSUM <br /> F (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 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address / /l by y I 16),RY26 6 — City oelfT+s,4 Lot Size/Acreage <br /> �r_E I Address !� � Clt Soal �P��13. �XLA��hone s' <br /> Owner's Name S <br /> ' -34 6 3 0AAG C 1 y+.,._.Ji4i7_C 'P16 � S''f <br /> Contractor yt crQ. Address ep D G. License No. 45 Phone <br /> 63 1 i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ <br /> Ce <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1OTHER C] Monitoring.Hell <br /> 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �— <br /> f._ <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �r <br /> f 7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4_ Specifications <br /> Cl Public C7 Oahe► � fl Delta Depth of Grout Seal 916 , Type of Grout <br /> .SnN GF low n1 <br /> I I Irrigation ,Approx. Depth I I Eastern Surface Seal Installed by /t t /t1 CO <br /> k Repair Work Done 0 Type of PumpH.P. State Work Done <br /> Well Destruction C) Weil Diameter ±!L <br /> Sealing Material & Depth <br /> Depth : re, s _ Filler Material a Depth 1—n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTION I I tNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ _ Commercial ___— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 to Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4Method of Disposal <br /> Distanceto nearest: Well Foundation Property Line <br /> i LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> { <br /> SEEPAGE PITS 11 Depth ,t Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taw`s, 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 /> The applicant mus all for all require spec ons. Complete drawing on reverse side. <br /> i Signed Title: Date: a7 <br /> �. ' FOR DEPAR MENT USE ONLY 1 <br /> aao <br /> Application Accepted by Date 7 r <br /> �tf_ <br /> i _ <br /> Pit or Grout Inspection by Date Final Inspection Dete 3'7` <br /> Additional Comments:' <br /> Applicant - Return all copies to: San Joaquin Co un y Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CCK EIVED BY DATE PERMIT"NO. <br /> INFO NT <br /> t , EH 13.24VIEV.1/951 �/�vv ��•� ��"ice ll�l.lJ3(.! <br /> EH`1-2e <br />