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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1602 E. HAZELTON AVE. , PHONE (209)X468-3420 dam►' �' <br /> p O BOX 2009, STOCKTON, CA 95201 N0 <br /> 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 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 Servic <br /> �"�" <br /> � 7 U>? �,�� City S�" 4 Lot Size/Acreage <br /> Job Address l �jr J L[� ! / Phone b—/U S / <br /> n Owner's Name — Address 1 <br /> e Address License No. Phone_ <br /> kontfactar <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION-0 put ofYService Well !=1 <br /> Monitoring Well <br /> PUMP INSTALLATION [I-_ __ SYSTEM REPAIR 'D ,f . <br /> OTHER ❑.y C7 <br /> .rte T DISPOSAL FLD.- -PROP: LINE--- --- <br /> DISTANCE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT5/SU/MPS <br /> #t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel{ Excavation SpeciGcatio� <br /> f_1 <br /> Domestic/Private 0 Gravel Pack ❑ Tracy 'Type of Casing-1 Other n Delta -'Depth of Grout Seal Type of Grout 1 <br /> V1 Public l J <br /> I I Irrigation t—.Approx; Depth I I Eastern Surface Seal Installed by _ ] <br /> Repair Work Done L] IType of Pump `"- H.P. State Work Done y' <br /> Sealing Material &'Depth <br /> Well Destruction ❑ ,.well Diameter Filler Material b-Depth i <br /> = Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 1 DESTRUCTION (Na°ilsepticable system <br /> m emit;pubficer is <br /> s installation will serve: Residence_ Commercial � Other �' 44Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depthSEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispos <br /> r Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of tines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> -� <br /> SEEPAGE PITS 11 Depth `" Size, Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1I 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 /> k rules and regulations of the San Joaquin County <br /> I 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 /> C 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 /> i C,:d <br /> pplicantmust cal Aor all required inspections. Complete drawing on reverse side. <br /> X j'� �lJ ��__ (� Title: - - - - - Date. .o <br /> FO EPARTMENT USE ONLY <br /> r\ Area <br /> Application Accepted by Dale <br /> Pi;or Grout Inspection by <br /> Date Final Inspection by "" Date .7 6 <br /> Additional Comments: <br /> Applicant - Return all copies to: Saxe Joaquin County Public Health <br /> Services, Environmental Health Permit/Services <br /> 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 <br /> FEECK RECEIVED BY DAT£. PERMIT'N0. <br /> E INFO AMOUNT DUE AMOUNT REMIT-TED CASH 1 <br /> 1:H 13.2{IREV.+/A51 C D 9O� BGG / i C11 <br /> I EM 7{•2e �? <br />