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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 0 BOX 2009, STOCKTON, CA 95201 <br /> PMUKIT EXPIRES 1 YEAR FR2M_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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> Job Address Z(2!`� - -- - ---- City Lot Size/Acreage <br /> Owner's Name 4fz l r �Q &,e Address Phone <br /> Contractor �[' 1 Address License No��T�� Phot+ �"Y <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service :Well GI <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing Specifications <br /> I'I Public I:1 Other n Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigalion —.Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done 13 Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material k Depth ' <br /> Depth Filler Material 6 Depth. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION LLYDESTRUCTION l I (No septic system permitted if public sewer is <br /> available.within 200 feet.) <br /> Installation will serve: Residence v Commercial_ Other <br /> Number of living units. I Number bedrooms 3 / <br /> Character of soil to a depth of 3 feet:.. _" „_.., Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartehents <br /> PKG. TREATMENT ALT. 0 Method of Diso'ossl <br /> Distance to nearest: ...Well Foundation Property Line ,I I f� : <br /> i. <br /> LEACHING LINE l]4"_No. & Length of lines Total Length/size <br /> FILTER BED G] Distance to nearest: WellFoundation 1 02CCJ <br /> .��:,.�Property Line <br /> SEEPAGE;PITS lt.Y Depth _ IRi g' I <br /> P i..-. ,Number <br /> SUMPS L] Distance to nearest: Well Foundation Pro dd <br /> perty,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 /> -- <br /> Home owner or licensed ageW'A.,sigaature.cenifies-'the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> employ any person in such mariner as torbecoms subject to workman's compensation lawsjof California,"Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in tba perform6hce of the work for which this permit isajj%upd_j.,sh <br /> tion laws of California." _all.t►tttPloY Persons subject to workman's compensa- <br /> The appfi st call for all r uir inspections."Complete drawing onverse side. <br /> Zee <br /> Signed Title: . Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Addotionrou, inspection by Date 7-q Inspection by 1� �/1 i2�r�late L <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 INFO AMOUNT,DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT N0. <br /> + EH 13-241AEV.tInst - 1� yah - n <br />