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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 4 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made,to San Joaquin County for a permit to construct and/or install the worts 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 S rvi e. <br /> Job Address r City Lot Si ze/Acreage <br /> IM1 `� S Pho ��..4Aa yb <br /> - Owner's,Nam Addd(eess ne�. <br /> ~.-`^;,� "�✓< '�,' �A� t°� �l/ !J� 110 / [l1�'r"'_� � ��j Z`� l 8 <br /> Contract Address <br /> License No.3_7 Phone -� <br /> TYPE OF WELL-/P-UMP: r -r- NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION o out of Service Well ❑ <br /> PUMP INSTALLATION;0 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER,LINES DISPOSAL FLD. PROP. LINE <br />" FOUNDATION AGRICULTURE-WEL-L --OTHER WELL- — .PITS/SUMP-S-­ <br /> ' <br />` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> l � ! <br /> CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> F1 Domestic/Private ❑ Gravel Pack M Tracy Type of Casing Specifications <br /> f'1 Public CI Other 11 Delta Depth of Grout SealType of Grout Q <br /> i I Irrigation —.Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. ' State Work Done=G vj <br /> E Well Destruction ❑ Well Diameter Sealing !4aterial & Depth " <br /> Depth Filler'Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I I REPAIR ADDITION 7A DESTRUCTION (.1 (No septic,-system permitted if public sewer is <br /> available within 200 feet.I <br /> d <br /> Installation will serve: Residence X Co mercial�,..,,. Other '��'"' v r.."•; .-' til ^>.,� �+. r <br /> Number of living units: Number of rooms_`� {, r A1001- <br /> Character,of soil to a depth of 3 feet: Water table depth <br /> j SEPTIC TANK ❑ Type/Mfg Capacity —No. Compartments C <br /> ..:.... ... <br /> PKG. TREATMENT PLT. CI `_, , :�, „# `� {.- Method of Disposal <br /> Distance to nearest: Wel(` Foundation 3 Property lana 44 (1 <br /> LEACHING LINE No. & Length of lines Tonal length/size <br /> I FILTER BED C) Distance to nearest: Well Foundation __�Property..Line 5 <br /> • SEEPAGE PITS 11 Depth Size "`7 ' Num_ ber <br /> SUMPS CI Distance to nearest: Weil Foundation Property Line . <br /> j DISPOSAL PONDS ❑ z <br /> r I hereby certify that I have prepared this application and.that the work will be done in accord nce with San Joaquin county ordinances, state laws,.and <br /> rules and regulations of the San Joaquin County t <br /> Home owner or licensed agerit's sig6at6re 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 tfiii permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California,." <br /> The appli ust call r a r !red inspections. Complete drawing:on rover e s a <br /> Signed TRIO: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ^� Date Area 12- <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> Additional Comments: <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 PERMIT'']NO: <br /> + <br /> CH 13-24(REV.iiesi <br /> EH t4.26 <br /> ►t <br />