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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> I ENVIRONMENTAL HEALTH DIVISION <br /> f 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P 0 BOX 2009, STOCKTON, CA 95201 <br /> UMIT EXP RES 1 YEAR FROM DATE 1t5SUED <br /> I (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 �/, City Lot Size/Acreage <br /> Owner's Name � � <br /> Address _ Phone <br /> i�F42\C3G� � ; 1,iL.\i� li C .; <br /> rt!2`3 <br /> Contractor Address �. a �_ r�7 �i:����zir;ww) Phone _ <br /> TYPE OF VVSLL'7PUMP:i'' " NEW WELL ❑ `' ',—WELL AEPLI:ACEMENT ❑ DESTRUCTION'❑ Out of'SerVice;Ve±l ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL' PITS/SUMPS r (� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ti} <br /> E Domestic/Private ❑ Gravel Pack -❑ Tracy Type of Casing Specifications V 1 <br /> ^ I I'l Public 11 Other `fl Delta - Depth.pf"Grout Seal Type of Grout <br /> �y <br /> t I Irrigation - —.Approx. Depth I I Eastern Surface Seal Installed by <br /> 9 Repair Work Done ❑ -Type of Pump .;H.P• State Work Done w <br /> Well Destruction Q Well Diameter 'Sealing Material & Depth <br /> i <br /> Depth Filler Material, & Depth <br /> _TY_PE OF SEPTIC WORK: NEW INSTALLATION REPAIRIADDITION l I DESTRUCTION I I INo septic system permitted it public rawer is j <br /> available-within_200 feet.) -� <br /> Installation will serve: Residence Commercial_ Other .9v <br /> Number of living units: 4th Number of bedrooms <br /> Character of soil to a deh of 3 feet: �' { <br /> r_ _ Water table depth <br /> SEPTIC TANK< 01 <br /> ❑ Type/Mfg 1 � � s Y' r"`Capacity '��� . � No. Compartments f" <br /> PKG. TREATMENT PLT. ❑ kd,r It,:c <br /> N' xTr Method of,Disposal <br /> V` Distance to nearest: Well Foundation �� roperty Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines t - Total len6th/size ' <br /> FILTER BED ❑ Distance to nearest: "?Welle''t % + Foundation Property Line+ <br /> \` I tcl 'w C <br /> SEEPAGE PITS It Depth <br /> Size Number + <br /> SUMPS Ll Distance tomearest: Well ' Foundation. Property{ne <br /> DISPOSAL PONDS ❑ � <br /> I hereby certify that I have prepared this application and that the work will be'done in accordanceJwith San Joaquin county ordinances, state laws, 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 perfofmance 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 must call for all required inspections. Complete drawing on reverse side. .? <br /> Signed •' s . . .... .- .. <br /> ` Title: f Date: <br /> F EPARTMENT USE ONLY -7 <br /> A lication Accepted by Date �"} L� Area 121- <br /> Pi r Grout Inspection by �? ateCPinal Inspection Dat <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health <br /> Services, Environmental Health Permit/Services 1 <br /> / FEE 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO OUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> EM 13-24 <br /> i i4 Re1R <br /> EHEY.r/N51 ,�� �� f `Qjf` ..� i <br />