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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 95201 <br /> RES 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 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 /> All <br /> Job Address E&EA—vo,151 CityMAlbdt Size/Acreage <br /> r cr I <br /> Owner's Name Address ! Td�a� <br /> Phone <br /> Contractor a Address- A� License No.d�✓ iG � Phone <br /> TYPE OF WELL/PUMP:, NEW WELL ❑ _ WELL REPLACEMENT I I DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC"TANK" SEWER LINES } DISPOSAL FLD. PROP. LINE <br /> a FOUNDATION AGRICULTURE WELL• OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial I- Open Bottom ❑ Manteca" Dia.,of Well Exc <br /> i avation Oia. of Well Casing r' <br /> L: r <br /> C'.l Domestic/Private ❑ Gravel Pack ❑ Tracy ' i* Type of.Casing Specifications <br /> I') Public i-1 Other fl Delta Depth'.oF'Grout Seal Type of Grout <br /> I I Irrigation .Aporox. Depth I I Eastern ` SurfaceSeal Installed by <br /> r. Repair Work Done 0 Type of Pump - H.P. State Work Gone.— <br /> Well <br /> ne, _Well Destruction ❑ Well Diameter Sealing Material & Depth <br /> Depth Filler Material &_Depth �« <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I i INo septic system permitted if public sewer is <br /> ` available within 200 feet.) <br /> Installation will serve:" Residence_ Commercial_ Other S�, OD AL <br /> Number of living"units: Number of bed ooms , <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK d T Water table depth <br /> e/Mi <br /> yp g Capacity�._� No. Compartments <br /> PKG. TREATMENT PLT. b � Method of Disposal 1 <br /> Distance to nearest: Well�� Foundation`- /__"_ Property Line <br /> 1 <br /> r LEACHING LINE Vf No. & Length,of lines: .- Total length/size <br /> FILTER BED n Distance to nearest: Well7F_'� � " <br /> r oundation Property Line <br /> rN $ "1 <br /> SEEPAGE PITS 11 Depth s Size w� - <br /> Number <br /> SUMPS Distance to nearest: Well G �� Foundation< �Proj3erty-Line- Sd _7 <br /> DISPOSAL PONDS ❑ � � i 'w %, " <br /> I hereby.cartif"y,.thatJ.have_prepared this,application and that the work will be.done in accordance-with-San-Joaquin county"ordinances,.state.Iaws, 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 forrwhich 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued;1 shall employ persona subject to workman's compensa- <br /> tion laws of California. <br /> The applicant must call kor all reired inspections. Complete drawing on reverse side. <br /> Signed �x J + �i Title: <br /> „..:-�. � '.'� pate: <br /> FOR DEPARTMENT USE ONLY <br /> . rApplication Accepted by Date` r Area p <br /> Pit or Grout Inspection by Date , i ` '• 1 <br /> Ficial Inspection b = Date <br /> Additional Comments: `_ • E <br /> Applicant - Return all copies to:."„San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> ' 1601 E. Hazelton Ave...R 0 Box 2009, Stockton,'°CA 95201 <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> • EH 13-241REV.Iin5) <br /> EH 14.10 l f f- L� a� S 1p► <br />