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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 95241 <br /> %P RES 1 YEAR FROM DATE ISSUED <br /> - (Complete in Triplicate) <br /> Application is hercuy .=de,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 Ho. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public HealthAer/vicMes. _f t I <br /> ! � � U � <br /> City /Loth Size/ eage <br /> Job Address <br /> ,e k -`Address / �+ r•` one <br /> +v' 9" 2J � .✓ <br /> Owner's Name N <br /> , 7 ff373- � ; <br /> Contractor Address. �Y" T G License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well L"1 <br /> OTHER ❑ Monitoring Well <br /> PUMP INSTALLATION C35Y57EM REPAIR ` <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I <br /> a IN ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustrial O Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> Cl <br /> Domestic/Private ❑ Gravej Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public 1.1 Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation , — Approx, Depth l 1 astern Surface Seal Installed by t C� <br /> .� Repair Work Done C , Type of Pump �y[� H.P.. - State Work Done <br /> t+�Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth <br /> 'D Filler Material & Depth <br /> — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted it public sewer is m <br /> available within 200 feet.- i r <br /> Installation will serve: Residence— Commercial '`,ether <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: +� Water table depth <br /> - SEPTIC TANK. © Type/Mfg . %XR'"'-"' Capacit Y No. Compartments <br /> PKG. TREATMENT PLT. 0a * Method of Disposal <br /> Distance to nearest: VIlell` Foundation Property Line <br /> t <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> f SEEPAGE PITS 1 1 Depth Size Number <br /> SUMPS LI 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 laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or I' 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 /> employ any peon ins h manner as t becomes fact to workman's compensation-laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t following: "I anify that i rfo nce of the work for which per is issued, I shall employ persons subject to workman's compensa <br /> l tion law of Cali rnia." <br /> 4 The ap icant st I r all u' s. C (awing arse si <br /> Sign ) <br /> r Title: Date: �^' <br /> r ed <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ,Area <br /> Pit or Grout Inspection by Date Final Inspection by Dat 1 <br /> Additional Comments: jf <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 /> r. <br /> FEE OUNT DUE AMOUNT REMITTED I CA8R RECEIVED BY PATE PERMIT NO. <br /> INF ] tag r� <br /> a 2f r <br /> FH13.24(REV.t/x5) �,Q� �p� �� � �! �/ C�� " !/ <br /> E1,174-25 <br />